Lemery, Infant boy Form VS 61. 6-8-34-50,000 (17-7901)
NEW PORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
'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. No96'$ 7 Registered No.
/ Town 472---
County (...�.J...IL ...�1. C .., V-illsge
of-City (If city,give street address)
Name of deceased Q tft(�'
Ingle,married,wid -ed, - /�
Sexi olor.V __'tL.or divorced (write t e word) Date " Death..( . 4. :..../...il, 193,5
Age Years Months Days . Birthplace.. .... . . ..... .. ...
Cause of Death ..2....6t...44. .
Certificate was sign '✓ --" , M.D.
Address cc r- �
Place of Burial (or Removal)..O�l-�...
(If body is to be tempora�v eld, in ace I er)
Cemetery A0 4.. Date of Burial .. . ........�..� 19 c 5
(If body is to he temporarily held,fill in ) ce later)
The Certificate of Death containing the above stated particulars, having been presented to e, 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 t basis thereo HEREBY GRANT A PERMIT !�fJ
,2,(4,,, ‘7/;/
(Name) _ f�} ( )
the.Op K.....:=...:."4. •• •� ,,�d to hold temporarily and �+� i., the body.
( or person having large of corpse) `' / %i (Inter,move,or,flier diispose of[state how])
Dated.. . ..1..0.® 19..7IT (Signed) '� ,..... /.
Local Registrar
This Permit(js 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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