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Roach, John Form VS tit. 6-8-34.50,000 (17-7901) 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. ,.... ;-3 St n y - Registered No Town CC _ \/��/� ,, County......, ' f e P: i,°d Village ,......t Y Y lL l�. �5.� '� or City (If city,give street address) �� QQ a ,„_,,,% Name of deceased ..P:Y..!�).^- �^ ,,, /� Single,married,widowed, - g Sex.......... Color WA- or divorced (write the word)...JMrL�4 Lt " Date o Death. r--L- - • r-L° 19 a Age q Years 2- onths -Z.. Days Birthplace ... Cause of Death - . . . Certificate was signed by...M. • ,..... ..1 ^.........: j�.. , M.D. Address �... ..S1....o�2�''! .. ... Z.rl 'z�-, •L17 Place of Burial (or Removal) _ .I.. '. .,mod 4. 1- ,Z (If body is to be tmporarily heldnfil in space later) /9 Cemetery I ' .,..... F -1. ^" ' . ru iL. .. ... Date of Burial.., ..?ti(r 1 © 19 3 S^ (If body is to be temporarily held,fill in space later) (/ The Certificate of Death containing the above stated p rticulars, 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 basis thereof I HEREBY GRANT A ,VERMIT to .l `Le.../..-/ / t 7,..e ::.., ei ... ......, / 1 ;P ,..P ... _ --P , (Name) { ddress) i the to hold tempor ' nd ,.:... :.Y the body. (Undertaker or person having charge of core) (Inter,remove,ov-erttforrAvin dispose,of[state how])" Dated...4.Gc x:.t.,- 4....? 19...3....5 (Sign iJ...�„,... ..Y..1.. 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