Spier, Lester rorm vo. el. o-iO. )-)v,UVv 11/.i't4 )
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ilir 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.....S0/ Registered No..,. J
Town
County � 1 e-1"— Village Ada__
. //,,��
or City (If city, give street address)
Name of deceased c -c:2- - ......... .. .. h.
Single, mar widowe .
Sex..Z.�'1p" Color. .or divorced (write the word) Date of Death...- z 7 19.s41—
Age ,-i 7 Ye�s� Months Days Birthplace
Cause of Death .'p -1-G,�Y.` '
Certificate was signed by t,--f "'C. `o24e9 .... M.D.
Address ! ,e.-- /
Place of Burial (or Removal) /�t^'►-� i'/1-P(r.✓
(If body is to be to orarily held, fill in ce later)
Cemetery .�X n.e Wfx.t.R s `..���i Date of Burial.... ... ... 2-'7 19.3s�.
(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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on a basis thereof I HEREBY GRANT A PERMIT 21
(Name) ( dress)
the to hold temporarily and the body.
(Undertac or person having charge of corpse ( , r ove, or othhery pose of [state howl)
Dated ...2g,4 1.9...3.1 (Signed) - ?.t��'s�C- rrLr,G
Local Registrar
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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