Chambers, William Form VS. 61. 8.16.35.50,000 (17.1423) -
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 CERTI•FICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No.T6 O" egistere No.../ .
Town / ,�
County l G�`c^��" �`-_ Village /cS2 !.:../v,
'.1 '°
Or City (If ive street ss)
Name of deceased. . .....
--"&6-**4"--4-4-----"
Ly Single, married, widowed, •ed Sex..J Color or divorced (write the word) w Date of Deat -)"./ 19 3 6
?A
Age .'2- Ye s S ont Days Birthplace.�e+�>c ... : i"�
Cause of Deatha�ZY� "•
Y��(
Certificate was signed by A.,�y� .y� M.D.
Address - j� � f''/�,/ ' j
Place of Burial (or Removal)...bf'"). .7 ''2'21'^- r '
(If body is to be pararilyy�d', fill in sp,_later)
Cemetery . ...... e..y ` - .. Date of Burial ' 4 19-.2
(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 theem above stated Registered Number,
and o basis the ofH BY GRANT A PERMITto.. 4/ ----L.__
GLi {
/1r• '7/.
ess)
the. to hold temporarily a the body.
(Un r oryer n 45 mg charge of s ter ove, or o dispose of [state how])
Dated.... 3 i 19 6 (Signed) ....
Loca Registrar
This ermit 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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