Barber, Addison Form vs.8L NEW YORK STAT} DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT ,
tar This Permit can be signed only by the Local Regtrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the F.ING and acceptance of a CORRECT AND RCOMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INB
Town
Village ---A,,,,-.....:�
Dist. No g �� County : ° c' (If city,give street address)
0 , (45_,,,„-f.„--city
Name of deceased .^�
Single, married, widowl, �_ ,„Date of DeathThk ........19
-or divorced (write therord).4 "' ""
43
Sex.�'X�..-ate-'Color...��Age I..5- Years 7 Months L..t..Days Birth place �-A j
Cause of Death ( '
(� � r M.D.
1...! JSj•+ C. . �'
Certificate was signed by /(�
Address
Placefoif Bto be toal (or Removal)yheld, l `� 19.
Cemetery y into be temporarily held,fill in space later) Date of Burial
(If body is to be temporarily held,fill in space later) �
The Certificate of Death containing the above sted particulars, having been presented to me, after careful exami-
nation. the same appearing to be COMPLETErORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have ecorded it in my Local Record with the above stated Registered
Number and on the basis thereof 1 HEREBY RANT A PERMIT if �_" c 1
to....... ./.. C (Address - `h"�
Name) I �. the body.
�� toold temporarily d ••
the...: n.er • • (Inter,remove,or otherwise •s se of[state how])
(Undertaker or person having charge of corpse) iigned) n - "A.r'Yi
Dated `Ylti.�4 19.. •�v Local Registrar
This Permit is sufficient for the,Removal (and Intnent or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by Conn carrier,in which case a Transit Permit (VS No. 62) is required.
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New York State Department of Health .
v7 6 ,- DIVISION OF VITAL STATISTICS
TDist. No inserted by registrar , CERTIFICATE OF DEATH Registered No r\.`)
To
• v - 1 PLACE OF DEATH: STATE OF NEW YORK 2 USUAL RESIDENCE OF DECDA D;{If an institution,give place o£
d O residence prior to admission.
0 td County .--ate - 1-° State �J
•
i
4. U Town L. County '-D ��
WA Village Town _ _ _ a_._,
cti • to City Ward Village or City
- a Z a No. St. No. St.
(If a hospital or institution give its NAME instead of street and number) _
W
o w Is residence within limits of city or incorporated village?04 c.,) C., ,6?1-4 c Length of stay:
O a rr 4, In hospital or institution--._---___yrs. mos. days 2a Citizen of foreign country (alien)) - .
yr (Yes or no)
x z 5 In town, village or city..- -.-._-_-yrs. �' mos days If yes,name country
1 i,, Z a Q� rca
id'. a '
dp: ; 3 Full Name L- .. Q. te''/ _ .
F c4 E. u 4 (a) Social Security 4 (b) If Veteran, MEDICAL CERTIFICATION
47 . Name War ---- 22 )_,-� rya • No.--._--- --. DATE_DE-DEATIi- (Month,Daysnd Year
W CJ
P. dW .°� - - gg3lD
a,! b 5 Sex 6 COLOR OR RACE 7 Single,Married,Widowed,or _ —
W u Divorced(Write the word)
" w �l �� (� . , 23 I REBY CERTIFY, That I at ended deceased from
T1, w �k—w r `}�J l , 19 to , 19`�
,„ 5 a0+ m u 8 rr MARRIED, WED OR DIVORCED,Name of Age if alive
r4taw (or)Wife,.
--y�� I last saw h alive on..-__._____--_-_.___._� K-44,t Z 19
Ls7 lr d u O (or}Wife-.._.......... .. .1a-�-�4J"".�> / IL-R r.uL.r years '------ �
N,,, ,p .k -0 -- To the best of my knowledge, death o erred DURATION OF
a R 9 DATE OF BIRTH (month,day,year) 7aC r• (�� on the date stated above, at Q m CONDITION
< '" Ti G 10 ACE Years Months Days IF LESS than 1 C Yrs. Mos. Dye.
OO O ^� J 1 r{ day, hrs. Im ediate cause o death._....-__._...-_
t m Q O 6 1 or- min. f /
W ! W A
I , C7 i 11 Usual occupation-__
F C� d u — — Due to --�
a9 W 5 w 12 Industry- or business..__.---•- `
tr I:^ `� a .", m 13 BIRTHPLACE (City or Town)
----------------------
v"� •" State or('ountr _ ----__---_.--------_
d .» (. Y) K/ L�r i Due to._ -?C�" ^ "�^
'in 0 64 14 NAME \J- ,tt,,, ('►2 t-r '-& t I -_
1. .� O 6. 15 BIRtate or C o (Cityr or Town) Other conditions
m • " (State or Country)) (Include pregnancy within 3 months of death)
w 2 W 0 Major findings:
GS y �, = 16 MAIDEN NAME ( � �_, % t!a-.1/a�-a .-� Of operations PHYSICIAN
T-
Und
e the
" o c 17 BIRTHPLACE (City or Town)`�� � � � cause toiOwhich
F J - a (State-or Country) ! t t) -q_ ate death should be
q a -. 18 THE ABOVE IS TRUE,TO THE BEST OF MY K OWLEDGE Of autopsy. - charged.
(5 ,O a' p-. Informant's own ( What laboratory test was made
.. k2 0 > signature a '.1 •
F' W ,Z y Address ( a- is 24 If death was due to external cause,fill in the following:
'�; M z' C Q 19 PLACE OF Bt'•RtAL, CREMATION DATE OF BURIAL (a) Accident,suicide,or homicide (specify)
7'- q OR F.EM,O3 A
4. 3 p WW Z 1r�^' �t • /y�l�•A e� q 19"L L (b) Date of occurrence
-
W., M Gy Ti a !' + I v (c) Where did injury occur?__:----_ ._
I 0 F 20 UNDERTAKER OR PE ON1 I i (City or town) (County) (State)
j 8 U • O W CCU. IN CHARGE (Signature l�� • 1v • (d)Did injury occur in or about home,on farm, in industrial place,in
t�t_1 W z e U ADDRESS. ] - .-. public place? While at work?.
r _
.., -4 U UNDERTAKER'S License No (Spify type of place)
w �Q� 'S (e) Means of Injury
740 O 21 Date received !"i '7 •- -�
• k -- �, ^ 25 Signature f •A`--klC.--- -- -- ` 1 M.D.
f t) 193 Signature oof IRIegiistrarr o S hregistrar Address_-I _'2.S�S4_'1&--•dam-J r' V- R.. .j ;Date. -t. l43
1 III
Burial or y ` j� r.
� Transit }Permit issued by t <Q ®4. .,x Date of issue