Colvin, Maria roan Va. 61. 3-16-35-50,000 (17.1423)
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.f .6.,I gistered No. S
Town 7 �����
County 71.441'141"— Village 71 �(y�'"mot.... . -
City (IE city, give street address)
Name of deceased ,..70
i4,41...2A,
grce,itL,:j.
_`�. ��f=*. Single, married, widowed, ��� /f
Sex.t.tr. Color... .... or divorced (write the word) . / Date . Death. ' " ....193 C
Age 7.,,c- Year /..6 Months / p /�,l 4 D ys Birth lace. .4 '..
Cause of Death '��a.�u -s%� ,�..1??r/ -01- ----4-
Certificate was signed by //- M.D.
Address 77;
Place of Burial or Removal) �/9 ''
(If body is to be orarily he( m spa e
Cemetery Date of urial Ale "2-67,1 19474
(If body is to a 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 th basis thereof I HER Y ANT A PERMIT O
to Q9 "-..."
(N Addre
the to hold temporarily and.... .. the body.
(Underta or son eying charge of c re) ove otherwise d of [state how))
Dated :L!f[i- 7�i 19)b. (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
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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