Nailor, Edward roan♦a Va, rl-c2-»-JV,VVV t1/-2LY4)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sur 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.`"-,!B ..
/ • Registered No
Town,
z , 6.-
County e f
_- L/ ( y (If city 'ye street add )
Name of deceased .* u-.- mil A1_ _ ._.._._.._.. . .. ..._ _ _ �...
Single,married,widowed, `�/�
Sex Color f�, or divorced (write the word)�l `e�y`� Date of�jeath �r 19.
Age (f G Years Months / Days Birthplace...._ �`��
Cause of Death l�ti��•"-- ----i---'f—e'
Certificate was signed by — ,2 Z
t z M. D.-
«
Address _.... ._ t_ �. Zz�-e_e_t ,.. ...
Place of Burial (or Removal) 7;--e-'---7 �--w 7..�`„.{:``, -
(If body is to be p rarily Id flui space later) -iii--` �— - —3 u-
Cemeter 'C �` `� .. Date of Burial 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 w'th the above stated Registered Number,
and on sis thereof I HEREBY GRANT A PERMIT G-
• kt
_.........�_.... .. �
(Name) (Address)
the "sl- "to
f l to hold temporarily and t e body.
(Und ker or persicati+ v,n charge ofskprpse.L_ (I ter, t_ ove, othe spos f [state how)).
Dated. c`y` �'� 19 (Signed)
C - i zz� oar
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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