Bullard, Agnes V . U.S. 0./4,,,,V,VVV t 1/•1,62) N
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT „
. .
Elllir 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.15-6 t-) ) Registered No.
Town
County 'eila../kAitef./ Vitra-P..
(If city, give street a ess)
Name of deceased Ati '(//-14-e-.4- /e-retreetter—
Sing , married, widowed,
Sex..7240ettet/Color.... .. ... . r divorced (write the word) re4).4,4Xer-vrt4" Date f ath .. , 0,2-4
Age 6, Years & Months .l.e t.Days Birttplace
Cause o Death Ail
•
Certificate was signed by — , ,,e ______ m.D.
Address . -(er.f.,o 0 r--I-•e-f, 17-
Place of Burial (or Removal) I hee,f,ziir,
(If body is to 1_,T,terpo ily el , in space later) Ct./74'1'11-- .''lge(XelL'> '
Cemetery.. PA Date of Burial / 1.9.e
(If body is to be temporari 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,
anis the basis thereof I HE Y GRANT,A PERMIT
to 2-- i g/tert/J cVs k-€.64erP '1'66
clAddr
the..f. ... --r, ... .. .... to hold temporar' and the body.
./ (Un e er or persop having charg f corpse) (In emOrothe dispose of [state how])
Da it (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
1\ or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
...."
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