Lockhart, Baby boy r rm Va. 01. 0-10.57.71),VVV (1/-14L5)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
air 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...e.5...‘.a/ Registered No.../9:1
Town4County .. .0-c-- Village
or City (If city, give street address
Name of deceased ....... ,
�� _ ngle, mart.' d, widowed,
Sex.. , "" or. . ... r di rced (write the word) 4j,..�. .. Date o" D�atthh .Jl.. 19.3.6
Age .. s.. �}vJlonths Days Birthplace�'' "�'�.... �...... ?n
Cause of Death....�....��ir� i--
Certificate was signed by '.3l'jj
M.D.
Address a -i....rl' j
Place of Burial (or Removal). ?'t /..iif/a-;zreees: . - i //- ,
(If body is to bet orrarily l , fill in spac ater /
Cemetery .. . . ...1�. v Date of Burial .. ..../y-/ 19.,3 t
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presen d 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 abov stated Registered Number,
and on the basis thereof I HE EBY G T A PERMIT 2.---4
("j-- el'A
I.
e) ddtess) Vthe to hold temporaril t the body.
(Undeytaker or person having c arge of corpe) e, or othe pose of [s
Dated....,.,.4(..itA-R "..... 19..3...E (Signed
l/ 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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