Bombard, Russell corm Vs. 61. 8-16-35.50,000 (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fillIF 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.....Ls-at,/ Registered No. / 3 -
Town
County G?-'Y,--•-,-- Village 32- 1144-01 - aI,-Q •< 4-,--, 'C •. '• y
or City (If city, give street address)
Name of deceased ---116 As .c,
__// ',I-
Single, married, widowed, �,,
Sex..*4) . Color N'A.44..or divorced (write the word}') .'.2 Date pof Death 4a.l'+� .19,, 19,i4
Age /7 Years Months 7 Days Birthplace-a-o- ' - Y ,, . y-
Cause of Death .¢ .0,.. ..r
Certificate was signed by 7 - Q' M.D.
Address �' `".1 13#7• �},,
Place of Burial (or Removal) 14 y 4-Nt� 4 • i "rf• V-
(If body is to be meepor ' hel , fill in space la
Cemetery. Date of Burial 9a---"M:---/ 2- Z) 193 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on th basis they f I REBY GRANT A PERMIT ��to goat^�+_ - - }...•.l[ •
� (Address)
the to hold temporarily and the body.
(Under er or perso having charge of co rase) a or o e ' of [state how])
Dated '. .r2-././ 193L. (Signed)
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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