Blanchard, Anna _... ♦o. US. o au n>> , vu lira•tc�,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lir 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, LEGIIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No.•-6-V f 7 Registered No
��A���t Town
County.:./14 Village �-
Name o deceased...
/1`s" _ City (If city, give street address)
'Single, married, widowed,
Se olo .or divorced (write the word) ? --- ate of Deatlt a 2 19 3
Age 4 iii Year 4• Months...7 Days Birthplaca, - f
Cause of Death
Certificate was signe by.... % Val .... ... M.D.
Address..... �a—`e-- G.
Place of Burial Removal)
(If body is to be to lily held, fill i space later) — /
Cemetery .. !u 1��� � Date of BuriaY..2f�ke.eif.,� ..r2, ' 19?
(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 o the basis thereof I HERE Y GRANT A PERMIT
, A (Name} (Address)
the �l to hold tempora • and the body.
(Undertaker or�pe��rrn having charge of corpse) ov otherwise dispose of [state how])
Dated.C.22.i .,LP'*...,Z 7 19.3.1f.. (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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