Bogle, Mary Form VS 61. 5-24.3 5-25,000 (17-8593)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. J.. -.1.L... Registered No. /3•
' Town ``����
County _.... . __ _ _ __ �� ._1..._..,,l.C..� , -
or City (If ci ,give street addre75
Name of deceased..._ _ _� ••- ,
Sin e,married,widowed
Sex....,, ` Color or divorced (write the word).... ...... ..............._....... ..._...Date of Death. _. - .......t. 19.J
Age Year i Months... %Z ._..Da s Q$irthplace ... 7,
r ... . 4eiddide*rl
r� rc
Cause of Death c.. - . .._..» ..... ...... ' .. • .....
Certificate was signed by .... M.D.
Address.. ... _ „ ' zs"c C 7 ,...
Place of Burial (or Removal)
(If body is to be temporarily held,fill in space later)
Cemetery -t- - -•- ~~y .F :..a. .•..,, Date of Burial.... _. 4.�Y•73 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 on the basis thereof I HEREBY GRANT A PERMIT
to i(Name)...................... — rcress)
the l to hold temporarily and the body.
r er or a ) (Inter,rt,o,..� otLea, . di,Ya of[,tdLe kow))
Dated.. / I . 19.. (Signed). ; ..' ..� .Loc strar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body ttoo iny Phrt o t e 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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