Diotte, Anna rwrmi v.a. aa. cr-io•>?-?u,UUU (1/-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or.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. c ..0.-/- Re ' tered No
Town
County • Village Cil-Z •
or City ,: . (1f city. give street address)
Name of
.
deceased
Single, married, widowed,
Se - ... ... .... .Color. or divorced (write th word) Date o- ea 7 19 a‘A Ye Mo hs or DA y s Birthplace..
Cause of Death
..,. ‘ .
Certificate was signed by '.. /e-e--
Address # , 02. , M.D
1P" '
Place of Burial fir Removal).. .•-dAr'' 0
(If body is to be te 1.,- 46, ;" in sp./ later)
Cemetery dr - ..071ere-a--- Date.of Burial .,/, 1904.
(If body is to be temporarily held, ' in space later)
The Certificate of Death ontaining the above stated particulars, having been presented t 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 e basis thereof I H REBY GRANT A PERMIT
•
a
X iz
(Name) ,
Address)
the to hold temporaril a d - the body.
( iiiikt k e r or person havtng charge of .r/ e) (I r, rem or ise dispose of te how])
Dated ta I w, (Signed)
Local Registrar
This Permit s sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su c to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
MI
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