Pettit, Margaret Form VS 61. 1.23.35.25,000 (17-5154)
NEW YORK 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.No. t576.0 I //J Registered No. /
County......Y.1..! .. .... .. e- ���� r7'A mG '9.2
(If city,give re dd ss)
/ / �/Name of eceased � t,-/t,�y , `�
JAG Single, arried,widowed,
Sex ...j....-.....Color....'.--(.} nor divorced (write the word) .Date o Death 7 '( 19 3 t5
Age 6 0 Yea 1 Months /. ./ Day _ Birthplace.`....„ ..„... ...
Cause of Death r,,,-,
Certificate was signed by Y j z C M.D.
Address
Place of Burial emoval)
7%(If body is to be tempor r. held,fill ipspac 1 ter) r/
Cemetery...._..._...„... .. --.... - -- „.Date of Burial - ve--may 2,t� 19. 1.5--
(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 act .ted the same for registration, h . recorded it in my Local Record with the above stated Registered Number,
and on t, - basis thereof I I-€ REBER• ►, C A nT g
to 4 ' - „ „..._ L.4.X ‘rer:,,,
(N me) (Address)
the to hold temporari ndOter,
the body.
x-er or
rrCpeerson h^ in charge of ps re other ise spose of[state how]).
Dated - • 19. .. (Signed) .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crem o ody to any art of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Tran�ft Permit (VS No. 62) is required.
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