Seems, Edward 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 WRI I'MN IN DURABLE BLACK INK.
Dist. No... !?D I Registered No.3 6
�7�'� Town i /�
County ..(!f -�-�- Village /'� i ` G�
/� / or City
(If city, give street address)
Name of deceased GI ' Vde.-2-vvg....,---'
Single, r ried, widowed, I
Sex... .Color k - or divorced (write the word)... Date of Death "7 " r 19 3 6
Age , ,7 Years „ - Months �,i^ Days Birthplace-- -7*4:-� *- -
Cause of.Death .. ....
Certificate was signed by ig' M.D.
Address �� ��`..) '- 'f.
Place of Burial (or Removal) „.,I /'41'1-"-'" &' 77'
(If body is to be yeorayeiy held space later)
Cemetery �Yytp / Date of Burial • ,j 19 sG
(If body is to be temporarily 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 asis thergpf�ER OGRANT A FERMITto W , ?
(Name) C%?��(Address)
the to hold temporarily and the body.
p g charge of cor e I re e, or oth dispose of [state how])
(Undertaker or ers havyt p ) P
Dated / 19 -if" (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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