Smith, Warren Form VS 61. 1-23-35-25,000 (17-5154)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sir 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 e' Cs�° / 7 Registered No /f7
Town-
County ...Pillage...
%/ or City , (If city,give street address)
Name of deceased � �..: ..: G ..
Single,married,widowed,
Sex ..Color....Colors or divorced (wrte the word) �1i1 � .Date of Death.. eZ 19/&
Age L." Year Months ‘. Days Birthplace. ._ . . r /y.:
Cause of Death...__......... .... .... .... ... . .��� .. ..���.. .. ...
Certificate was sig d .. .. . .... 7 �'! .. ... .... ... - M.D.
Address.:: .. ", .�, _,
Place of Burial (or Removal).... .. .. .. C4
(If body is to be temporarily held,fill in space later)
Cemetery.... . _.. __._... _ _Date of Burial................. . . . -Z 19 (S
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to e, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acc ted the same for registration, have recorded it in my Local Re ord with the above stated Registered Number,
and on t asis thereof HEREB RANT A PERMIT
to... , t --(-7,-- 1 — , 7 -4Q,%, L_...A__ -
(Na ) (Address)
the .... to hold temporari y nd the body.
( aker or perso h mg charge of corp,t: er,remove, er se pose of ate how]).
I
Dated.... ... 19.a3 s (Signed) _
Local Registrar
This Permit sufficient for the Removal (and Interment or Cre 'on) 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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