Smith, Mildred Form VS 6i. 6-8.34.50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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.t--9 oZ G Registered No. /
County ... .... Village• .......Pc�� �-
(If city ive street ad ess) 1
, __.?
Name of deceased
�rrgle,married,wirtlovPed,
Se .. t rl Color �d e eed-(wri� the word). Date of Death.d- �� 193 G'
Age Years .... ....Mont s �4._.. Days Birthplace v
Cause of Death ,7
Certificate was sign by IV- ill' -1- M.D.
Address G � ,::..
yfy
Place of Burial (or Remova )..... ':.-c-c 2/
(If body is to be m r ' h , 11 i space later)
Cemetery,.: y5 • • • : �-4-(2/ ••• Date of Burial ,/, 193
(If body is to be temporarily h ,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 HEREBY GRANT A PERMIT
to % ..s , , Via% ; A7 47• 1
am (Addres
the to hold temporarily and the body.
ndertaker or person having charge(4 co se) (Inter,re e,or otherwise dispose of[state how])
Dated l Z 19..s.7 So (Signed) rl
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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