Minor, Existe .m VS 61. 1.23.35.25,000 (17-5154)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sir 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, LE ,,G�I ILLY/WRITTEN IN DURABLE BLACK INK. /
Dist.No. ..5 ' %..1. Registered No.
y � Town �L�G' �a_
County � Village
or City (If city,give street address)
Name of deceased....L i)--- ?'7(...-.!,,Y./.%.-��`7----.....
����// /��ingle,married,widowed,
Sex. �'!"�___....Color or divorced (write the wordd "G' Date of peath... 19 3-"
Age . Years.....,.,. Months Days Birthplace„....= -� -
Cause of Death_..... .... _ --
Certificate was signed by.. . ....
-...„.::,.... _...„ M.D.
Address.._„ „....---
Place of Burial (or Removal) C ��
(If body is to be temporarily held,fill in space later) .
..
ate of Burial 193�'
Cemetery. - ._ „..._ ._. _. ..._.... .. ...
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above st ted 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 as ereofJ- HE Y GRANT A PERMIT �
Na (Address)
the 9 .. .. : . to hold temporarily and the body.
(Unde er or' on having charge cf corpse) ove,or o erwise dispose of[state how]).
Dated........_...._ .. .. ... 7 19... .r? (Signed) „.. . ..__._. ..............„............_ .. ....
Local Registrar
This rmit 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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