Van Denburg, Francis F vs 61. 1.23.35.25,000 (17.5154)
ri' _form'' NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Orr 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. .,„1" " K Registered No 7
Town , o
County 9,G,-"2-, Village s1L---- ��� -Z
�/' or City (If city,give street address)
Name of deceased 1 -i-e' -
Single,married,widowed,
Sex.. .Y�_......Col of` or divorced (write the word) �Gr- ...Date of eath �� 19.. }"'_
Age.........._... G Years Months Days Birthplace..—�- �—e— .��.�- �. ..
Cause of Death.. ._......... r �k� w
Certificate was signed by �G M.D.
Address .,. .,,: - �•
Place of Burial (or Removal) 0ee. .... .: ..»,C
(If body is to be temporarily held,fill in space later) ��
Cemetery.. .
slu/L Date of Burial. �' z7 , 19 -
(If body is to be temporarily held,fill in-space later)
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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on the nth/7=EREBY GRANT A PERMIT
toV __ _.� __.. ..._...._ _ ..
e) ��, �' �v!/ (Address) ...;
the _ to hold temporarily and the body.
(Un il take/0 ,person having charge of corpse) I t vr ore,or therwise dispose of[state how]).
Dated , / 19 , (Signed) � Z
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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