Smith, Lula Form VS 61. 643.34.50,000 (17.7901)
NEW FORK 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. 6...Q..f. Registered No 3/C
�� J Town
County .. ... Village
or City (If cit give street address)
Name of eceased
`/ Single,married,wido d,
Sex Color Z/V . or divorced (write the word) ' .Dat ath , .o .C ...19..c��..a�
Age -a g Year Months f Davis lair place `L /
_ ��
Cause of Death.................... ..; a5 r. ,.
Certificate was signed by , M.D.
Address C.4.-.G.t-4 zt/
Place of Buria r Removal}. ........
(If body is to be to eld,fi n ter)
Cemetery Date of Buri -i ` r� 0 19...c .�-
(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 acceted the same for registration, vie recorded it in my Local Record with the above stated Registered Number,
and .n h= basis thereof I HER Y GR T A PERMIT
to - . Za
(Na e) dress)
the to hold temporaril -d ..the body.
�ertak7r or per n ha 'ng charge o€ rp ) remove,or o i�di [state how ).
Dated .4-Z 19 a2 (Signed) ...
- cal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) o a b/o y to any rt of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit rmit (VS o. 62) is required.
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