Thomas, George Form VS 61. 6-8.34-50,000 c i7 EW 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.
Registered No
Dist. No. /� �•l
Town . %
County r U� Village
(If city,give street address)
(� or City
Name of deceased........G
Single,married,widowed, <� Date of D ath �` 193s—
Sex 2Y� Colas" or divorced (write the word)
Age 0Year ....._.. ../.
Months / �— Days Birthplace 7
Cause of Death -••• -- ` -•" '
/f j�G`� �. , M.D.
.. .
4.
Certificate was signed bby.„ G��c •� ��� 'j,T
Address . •�� •� �
Place of Burial (or Removal) �j 2
(If body is to be temporarily held,fill in space later) G27 R Date of Burial...../ P b 19� `
Cemetery
(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 " t ,
IJam )
to. o�.��'r7.`"' (Address)
the " to hold temporarily and the body.
CUn$eftake r person having charge of copse) (I t , ve,or otherwise dispose of[state how]).
Dated 17 ,�‘ 19...3.,E (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) o 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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