Trombley, Frank Form VS 61. 6-8-34.50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
DU'This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. .J 6 c I Registered No. 8'
Town--
County W Vi-liage
er ty (If city,give street address)
Name of deceased C`' ..
C/ f
Single,married,widowed, •
Sex .. 1/ - Color.... ...or divorced (write the word) 7 Date o Death-��' s/e2- 19..Age `? J.. Years fa Months .aL0....Days a thplace
Cause of Death •
. ...
Certificate was signed by J�` + , M.D.
Address - k Q
(-/ / /�(1'4 - '�a.Place of Burial �: emoval �.... .. .. .. . .. .e r .. ..
(If body is to be temp.,:ri .eld,fill i - ce I r)
Cemetery ®T..../.. Date of Burial....c... . . fc1 19... ...?I S"
(If body is to be temporarily held,fill in space la r)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce ted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on basis then I lip'EBY RANT A PERM T ig
t o C- &t,e,41
( ?-117 ,
(Na (Address)
the ��-e---i., to hold temporarily . -79 the body.
( or erson havvigribarge ores ,rem ve,or o e d' to ho 1)
Dated i .19... (Signed)..........
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematiofi) of v ody to y part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit ( S No. 62) is required.
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