Brown, Charlotte roan va ea. i 1-z3.330O,UOU (17.3194)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
nor 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, LEGIBBL RIFEN IN DURABLE BLACK INK.
Dist. No Registered No
Town, ��
County.... Village _.._.. ._.: .�
�� // /-"— or City (If city, give street address)
Name of decease �'
/1-54---6"-4-1-i. .
Single,married,widowed, ��
Sex Color �' or divorced (write t e word) '�'�' f1��c. ..Date o D th... .. ...................... .:. . 19 SO
Age Years • Months..........i ,.:.......Da s Birthplace.
Cause of Death jj��........_r �._....
Certificate was signed by Y M. D.
Address......._. _C-tiA-a . -Gt__
Place of Burial (or Removal).... .. .__..........._.........._.........._.......
(If body is to be tempor r'ly eld spaceCj►'r ,
Cemetery Date of Burial... Al. r 19
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been pres ted 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 ,the ba s thereof I EREBY GRANT A PERMIT j
to o /LA.et fit, � (J t ! ,
(We jTT (Address)
the �C�J' to hold temporarily and `� _. _... ... the body.
(Undlher or rson having arge ofScor e) (Inter rem o ther�ise ' ose of [st l .
Dated .., 4 19..4. .. (Signed) e U' �/
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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