Smith, Earl 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. 5'6 o I Registered No. / F`7�
y �) own G T
County \tillage
GT City (If city,give street address)
Name of deceased eCt.,/?..Z jiY � ZL
Single,married,widowed,
Sex .a Color..�..or divorced (write the word).. .. ........... ... . .... . ...Date f Death.... 24( 19...a.a5
Age 1114- 4 Months s 13irthpl ce...._ ,Lei
f
Cause of Death C,(f_ -- ..1 ... ... ...... . ....' - -1..�<..,c-_•U -Q ..-
Certificate was si �- .1 t M.D.
Address.._....._................... .. -5.�1... ........
Place of Burial (or Removal) - .�� l. . ((-6-Q-ti-4Likt4CA44,t441
(If body is to be /a i.ly held,fill in spat ate '
Cemetery....... ' y�. �:.�5../1!5. ..... ... Date of Burial.. ... .. .. ... . * 19....3...5
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been pres ted 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 cal Record with the above stated Registered Number,
and • /)he basis there f I HERE
Yk2ksk.NT P RMIT
to 4l`/l ..... res .__. ..L7A . ..,
e) (Address)
the to hold temporaril -nd the body.
(.r ertaker or perso Lavin chaigz of c ip:e ov e v e di ose t to how))
Dated
-rotal Registrar.
Thi- '•rtuit is sufficient for the Removal (and Interment or Cremat' o a ody any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case Transit Pe t (VS No. 62) is required.
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