Shaw, Franklin NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
az This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District(Town,Village,or City)in which the death occurred after the FILING and acceptance of a COR-
RECT AND COMPLETE, CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No.. ._�1..-� ? Regist ed No
ounty_.. `jr1_.__--_. _.. Date of Death._e Cyy. .L - Q' I .2.
C
Town, '' Sex -_lrA ge____//
1__Yrs. Color- ._ .._ge tt
(If city,give street address) (Or Mos.) _
Cause of Death_ i�__
Place of Burial(or Removal).__ .v1_" 4,344 -,arJ;,Llw ..... e-44.4"^'
Cemetery `-� Date of Burial ---egoCe he..Ig._��
Certificate of Death of JJ''L - „...deaa.'.e4r f
(Give full name of deceased)
having been presented to me containing the above stated particulars, and, after careful examination,
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 abov st ted Registered Number,an on the has' thereof I HEREBY ANT A PERMIT
to ._ of u /_
( ame ndertake) (Address) lif
the to the bo7•
( rtaker or perso ving charge of o se)_ (Inte move o othe is of state w)
Dated___ t / Ig-, (Signed).. - -- --
LAIR; ' ar
This Permit is sufficient for the Removal (and Interment or Cremation) of a dy to any part of tke
State (subject to local cemetery or other regulations), unless removal is by common rrier, in which case a
Transit Permit(VS No.62)is required.
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