Cole, Rachel Form vs 61. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
..73,Eir'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.. 5-C.J--.7 Registered No.
Town
County --3/(...)a-Ve-t--2--t--. ii-il-ia-ge
ortify (If city,give str address)
Name of deceased J.i elee—,
. Single,married,vvidowed, • ' ' 71 /
Seaf-'nztie„Color.. .or. divorced (write the word) Date ofath.. ..2 2 19-1(a.
Age 7,2, Years Months... Days Birthplace ----/ -21.da......... .,7,Z;?,/7.„
/— • 4' _ /
Cause of Death .6.4,..:-44 .4'..:.--si.;:4././. .4' ,
Certificate was signed by...4,, i` (V' ,_.,.40!..1-.4- / , M.D.
Address -74- .----
Place of Burial (or Removal) Cz,z4,12,:ar
(If body is to be temporarily held,fill in space later) ./
Cemetery Date of Burial ,k2
(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 cmIi tie basis thereof I H , B /G7T A PERMIT
/
dre
,.._,. 9
c'2,2 ' - Ajili "-)--
gl.-.. 4c-e64-
(Nam , 0 dss)
.."-,7''
the /t/re-iya..1... to hold temporarily the body.
of(Vni..crtakerAr person having charge o,t,cot-pse) (Intene OtheprVis ose of state how])
Datecl...L4?:1/..-t.. (Signed) ° 72:1-- -1/) ..---/ r,
..1...-
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.
Z E.y O ^ ^-0 V•-r ^ .
p . v O c OM•�.0 0 0.Mo O: ON bq U w 0 w vi a t,-.v, rn v v vs w En, v
m w.0 s. ,.�;v,4 w
W 10 ta.^.^.4 O V., O 0W�Z
� yn a s>w � O M wM > 4-b -' a v)
I, pr nO aVw,r.�.^^'a0a, MM � , '� M0o O M � 0 o V vO. 7 Ou..' - +� 0 a�. Ov °.y
w Q; W v 7 cdNsp 0d 1... v at' ° ate c ,0: M o 6.o .wo . - .,., L �" ukipy , vOy yv = v y P y.-ra v
y O v 4 ° � a na ; a'a �, ^ OS ad0. o �^ al Y r�w
a , � ~p >~ " � oo� �Y aa a•9 �• bo �.a.vvv v M -
aW W34 MOoy^ v� o �w v + 3- ' a x �:a a,_>
, �
•
Ooo O -' U 000 "SW .3 ,n 1. M , .. .^ enao ,,, Mo uwq ea
w w 0 = toM . ,S M > V O••. vw , 'v"0U V 0 0 p3ycd' .0• , ° 00 v -.3� d ° 0 °"" av � � 0 ,o. va y
Nut' � T O b' •0 O L.^� p v.up M v ° .°'O " � vv a � " ' �n Z
a ,"bNU , p6U v ..0 O(A
•w
W
I.., Mi.--,'^ � H + o .3 I.
i v,F+ a'bY 'v .4 a o
4Q4
,:W".''y U v n � , ': di ".,n a b4 ° G�M3 'b > w 4-, - H 4:),:Q Wp d, e•^ � -o g M m M a) . o M �:.-6' b0 aa' j -� v t., .a. 00E °by.ro � i, a dU 0 ,4 p,oc),40M .^ , -• 0.0 bop 1 ! ii!
miIdi !
ej I. . O en i., 0 y + b ,. a o„yyp ,. � �� � ofu c°' ~Z aM vv Noo o ~ ., o LA E., 0:q Cv 'bvaVN1a•+9-d °' N0xi.4•-M 0 -° ao H �o. 2 w.:n•v o a M � ti 3 W4O"4W ,,wW � �,b3 .- N � y� d v•,0, pv ° LH.V �a, > v v �� hai.„ b o , v.4 �, vp'7xU ° v v v w HM2 ow-Wyf., iMv. ivo'V�, +' N ° •� Mdiaiv � v., , vo nobpyc a0 dUO
Ot
ni 0--, .0y >,> - _ d � I. • 0 WWI g usdDAoI Eb � w.a ° � iO° Na ° yc , r CA
fNp , v^ F. „._, 0 > V74dMQ � iv� •� +aMU S.� .0 I-,
w � ava 74 v � v s ya vGO0W� a„1 eiEi Ho p u•i v I. a . , .LM , u, .a - y.
,. o °~.- vp .. . v J1-1 ° .-, {-. a 0... q„C a, '7 '~ v v>~wpb.O , A.: > urbZ Wa
d'. w .�♦J v0 zN �¢ da Z a `° gZO801, ,- 0rd-c-c � ..4 V 0, cd 0 -.-. 6. 3 wct 0 �,-680,77 c0 c n 5, >>'..VT..., "C .� ° . 3 r ,yy.^,?
d0 . " o 1 T�'b+,'•a ..co M > s. vv1-. a, Mbd ,.vya›.,° .;x 11 ,.,' oa ,, Ga O � 5 `an ao •uv ..E wU 5 t. v ••0 wO.a .i. 0 }' t7 v, v.-. 0 a , cd � s •OQZ: V.,• HE•+ oFJ., 3„ •yr .0y-0 v_v " 0 - yu, vtcAv^.`*`tyOC MO a >�nal�E"N
� c : .L Ota-1 _ ,� a wr. p0O vv.G Ct ° oidM � , -_- v aZZ `wo)p. ► • b.� ��. . 0M - � •0,. _ M ,
•
°'a �•b . ' vM a o + ; ;- :
; 1i da p b/ fh it b .'d M ° yU °• 91
�, . '0;; o � Fz� 14X a iw:a •oMIZ oowcn...• > 0ci86) uabw ,� ° 43ap > a� o `.oa ~b_. CI ° � ° V z LV WZd � 0 3� u F'l a 1nca^° o ay '" > ,,w is ° ° M . v" MM oai•^ a > vy ^
� . ��o04. ill
^ oy ,-•o °rahb -v' Ocd ° v`• r4.ab o o� ',.°•" va ° vm•a a� i?� o `n� v ,a p N�i "I4...E
W '8E.i : Fx+ M o •4 o vv.Eb,. aZ oW ca a H 0-. H $, v�ac : v o0 ..i " d�, 0 N ~^a-0 v 0.n Pgyp.0 da M82�'iMo... : `nvm... a� 00o vM aw ,,"cOv �Qa0oo
Q(n ZE 4 — 11 � O pu .^ , 8m E 0* Mvn�o� E °N ° � Y ' y �w•ti[4 vWW ' v) 0Ya �,t000raao -: e* 0a p� * ^y' ..5. , 00 � Z d ;b2 0-, ,A u QV][-i / m � > y°' ,- vaov~'+- ,. ' ° °-a o�a � �x��wan v'� bMy o M a.�, �o o >~ -Jo m M'� � a,a•EZK ? & ° W'v8 VaM- ybMM • '.7oo 'ao .a a* o °.. p0 >Mwv, ' • vm , m� 8O6 .. .,. ^ v, roO d00E0dQw. a,i, ,. , vF,•bay,-... m wvt — a.3 y...0 '.. i '' .0+ M'^ 0.. .."cl , M N d'. s'�ypQtd u .a v > v ti O. v V' .0 '-• 044 O O .�, Mrnw V O+' Eg 0S � y� 0 i.. '0 bU.a ."0
L•Q
aa,ed E... ..: 4 � y ,. vN p ,.0--w v 0 °.> y� M.,.-:M 2 4m `n ~Trip'- a.. -.Mm wa ,, ,,, . ti(J, n °' 'i-- v0 .. OOo
ya, M p M � o , vood a., n i mo di ^ aaa , . >+• M00Ns.
Ei)
Wil ° 0'^2 E1' vTR> • w� v "" �• v Oa va N t.. ... M v ° v >b ° tin-a 0 °V Qe AO• g4)4 Ny :., 0 .0CA l0W 3Wa03aOa,c t yaa30 v � 0 b �m ,I) A0 O t a y 7, NMy'tb O." M bq,a;.-.'> .+v '"O E„ i'g iw> O .- v, v '' �-0vE ) aoa_, 0 a° = '-' 71aM .6 - n -aaeaO -ciea. X.,_, cqeaq ao y • vao , °a 3 aON� 7 W ~Q O CA° u•+ 0vc.00a e) vt •_ ..„4-,,, ,"Gy, . U ° O a, >,,L' O > w V 0^" 0aWao,UM'C Zcwavwav3 a F ° ' 0oO� a ,ti'y o': ° ndovoyv) „.i..A ) °>4 0•Li nv p •a ,. 0yv > a1 ,a ~ >.o ° voo an > S MvcoM > M .` o.0 p4....4 � tow ta
Z ; Sor,QQ wc °' od °' hMbb'� � M v dM o� '^cd
a, 0 a v� Fv,4 . Onmt., 0 .v.c7r ,.bon po�Na oaEM"^4. ..° wL' "Y '',. iwy aW � mCLAZC B ° 0 ' a:' • aad �: � OA � "" a °�� v. v� bua
i w � cc oc, ,. • ' 0 ° a'= > o � u: , ,, o. ? a � E� ,. v 0,3 ,. 1. M , � a). n 4 a ,. Eo d i V xro ar,-, w a -� �; ° a ovaNa aoA " p •via.0 �. v •;, o >w33o ,. a� a "9•5. .a�-- ... oo' lv. nw o ,aaov� a'd ,vo.n'eZy E-ta
• •