Potter, William rorm vaot. 11.23.33•SO,UOU (17.3194)
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, LEGIBLY WpI' T
/ EN IN DURABLE BLACK INK.
l�
Dist. No.. `7 —_ / Register No...... ..»..
Town, ^ //i
County »....... . »..» -Village
�
or City (If city, give street address)
,/
Name of deceased �l
Single,married idowed, -
Sex..? Color ' �
i or divorced (write the word ._»..».»....... Date of Death .. .. ...2 19°��
Age 6 2 Years SP Mo ths.... '2 D s Birthplace•
-`�41----c-()
Cause of Death /___.. ... .. _.»... :. � �S.t�
Certificate was signed by _........».... »....•
M. D.
Address
Place of Burial (or »».».....IPA J �_-�C-Ce ... ... �-C�
. . M".. /1...»
(If body is to be tempos 'Re val).1 d, fill in pace r: 0
Cemetery �'� :�!�J »» Date of Burial LY d 19 3 J
(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 bass t ereof I/ EREBY G T A ER IT' ilLc,i , �� v
to ` �.))
(NaptE j / (Address)
the. to hold temporarily and the body.
(Unit er or person avi charge o c 'Inter, remove, or of wise is of tate o )
Dated 19,5J (Signed) ���
iLocal 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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