Sisson, Mahala IIA•••r Y W.F.•••I a to Of- 11I-83811
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
4ar'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 - Z.,e2": Registered No
County - ---- Date of Death.Y 7 ` /z ..93.3-
Town,ail-
aS or ity. Sex_- ._- Age- _,.f Yrs. Color_. --
(If ty,give street address) Mos.)
Cause of Death ,I—_1/=..�'u':�1�.�-s ��_ -Place of Burial (or Removal)_,11 1----41 ,--- !�� Cam"
Cemetery _.._.._._...._. .___. ._ _...._-•-•___D to of Burial�lZ_• _igS i,
Certificate of Death of__. j1r --- •---- .-.
•.-
(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 above stated egis ed tuber,and on the basis thereof I HEREBY GRANT A PE IT
tors � , t---7-.-t- .=— _egi - :1,D�
(N e of dertaker) ` Ad ess)
the
- the body.)
(Un person having- of corpse) (Inter,-� ova or of wise dispose to how])
Dated__ ._ _ .44,. 193.57 (Signed)-__
Local Registrar s
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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