La Fountain, Edward Form VS. 61. 8-16.35.50,000 (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ilir 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, LEGIBLY WRITTEN IN DURABLE BLACK INK.
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Dist. No..0.
Registered No.../.4
Town
Count '` 4.rzz. Villag — '— °`
or...Clty (If city, give attest address)
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Name of deceased `—�'°��"`"
.........
/�mgle, married, widowed, >�� - ��
Sex ...Color A�!'dw( er divorced (write the word) /r/ Date of D ath 19
Age Kt.. Yea Months . � Days Birthplace�' ��� x/ ,�. ,...
Cause of Death"'',..'w _.......... _.....
7
Certificate was signed4 M.D.
Address P
Place of Burial or Remov 1) '-sue.. . f• Q2 ••••} `� 7. f�
(If body is to be ra ,(,ldin space later) , • / '?Cemetery ...._:..... ..::... .rk....,... • ,::.....- ' . . . ... Date of Burial ;IV2 ...,�1 /'`if 19.s:?.
(If body is to be temporarilf 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 the basis thereof I REBY GRVT A PERMIT Al
-- 7 ".?!"?
to .. . + y , .elf^ kF- Address)
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the ; . '•••-.•... to hold temporaril the body.
(Lin er or pe on °t$g charge of c� ) er, ae, or otherwi spose of [state how])
Dated " -- f ..yyr 19..c..z (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 Y
or other regulations), unless removal is by common carrier, in.which case a Transit Permit (VS No. 62) is required.
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