Forbes, William Form VS. 61. 8-16-35-50,000 (17-1423) • .
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
OW"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. Cr Of /J-4
County - -.,-yz.--- Town
Village . "7
tA-al N°..
Name of deceased .0-&'01L.--"" •e---01-Arag.--
Single tried,pi or y (If city, give street address)
Sex Color aritirt,..or divo, ced. ( Trite the widowed,word)414 -24-4:-"--- Date of ath::A 41 :193.6
Age 6 ri Yea it Months J Days • Birthplace ..
Cause of Death ' •
Certificate was signed by.... • 0 M.D.
Address
Place of Burialor Removal) 79/--0?-1...914q-44-40-101-e--- —t ..y. r.- y
(If body is to be oitarily ill in spac t il
Cemetery 46-/-3...e VA.-14.4J Date of Burial
7 193 6
,
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above shed 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 t basis thereof I HERE Y GRANT A PERMIT
to r: 4C+-4--- ,< .•i, ?.,e dress) 2fr—V
(N Ad
the to hold tempora ' d. the body.
Dated
(Underor person !sing charge of corp,o) , remove, o "se dispose of [state how])
if 19 7(-... (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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