Brugal, Myrtle Form VS. 61. 8-16.35.50,000 (17-1423)
NEW 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 CERTI'FICATE OF
DEATH, LEG BLY WRITTEN IN DURABLE BLACK INK.
Dist. No....� /. v Registered No.
Town
Village County (If city, give street ess)
�j�yt-/&-- � or CityName of deceased . .•,r •� _ e1ingle, married, widowed Date of Deat . ... 19..�
Sex .. 11 Color let/ or divorced (writee the word)
.5.7
Age If./
Yea ...Montths !J ays 6^ Birthplace
Cause of Death ..e..
/,, ..�l�C M.D.
Certificate was signed by �.� •'
Address6'
Place of Burial (or Remov(If body is to b e poraril Id 11 n ace later)Cemeter Date of Burial �1�/J�
19 ,
y
(If body is to be temporarily hel 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.ia accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and nth basis wtherreeof I HEREBY G ANT A PERMIT k
t0. ( '' / e T ( dares.)
(Name)•••the to hold temporal' and the body.
( nter, remov a dispose of [state how])
nder er or person having charge of corpse) \
Date .... 19�15.6. (Signed ' ,,�_
Luca egistrar
his Per it is sufficient for the Removal (and Interment or Cremation) of a body to any part of State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS N 62) is required.
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