Mulford, John Form VS. 61. 8-16-35-50,000 (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dr"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, LE IB W„.5.7 TEN IN DURABLE BLACK INK. 3 /t
Dist. No. Registered No. (p
r u:,_sX County -
...' TAa;rliag �y �- U
e
..+E;r-Ci'ty (If city, give street address)
Name of deceased... .. I
Se21��JJ��JJ� p ,Segie, ntai.i,d, witAed, 74
` -dolor d (write the word) ' r' ate o .--peat .19`.,CoJ/j��
Y rs 3- Months Days it lace
Age e Y
Cause of Death
ti (-- lam :... f,
Certificate was signed by.. ...
X.7-#--te..S. e..r.,c) M.D.
Address I.
l •� r•
Place of Burial (or Removal) . ��.c... l ••••• •• , � I
(If body is to be temporarily held, fill in space later) /�
Cemetery Date of Burial 1� Ct 19,.. t1
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to m , after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS EQUIRED 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` I GRANT A PERMIT. 4
z/ ;;�y , .
to '" (N ) �p (Address) '
the to hold t porarily d ..7 the body.
U er er or person havingcharge o c s remove, or o se spose state ow))
Dated.. / / 1. (Signed) �... ..... _... ..rt.e,t:,,„a
Local Registrar _
This Permit ' ufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject t ocal 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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