Downing, William r•..rm ♦a. or. 0-i0-3)-9U,000 (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mir 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..0 ? ,`L,..y.....•, Registered No.
it—WITCounty
••t Village. f`,(
41s , (If city, give street address)
Name of deceased -vt1, t , J. l �c--w---vkAA.�,
, 11!! Single, married, wido d,
Sex`1AA...t.........Color lA k or divorced (write the word) M,.. . - Date of Death.:IA/Mr 19...,2-.2
Age b ! Years Months Days Birthplace
Cause of Death A �44! 4`,S rf
Certificate was signed by VA, M.D.
Address In 4 r
Q y1
Place of Burial (or Removal) ecgA�. . 4- \1
(If body is to be temporarily held, fill ins dater)
,j , -
Cemetery .�w�• Date of Burial . .<ra19..e.fa
(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 on the basi thereof I H EBY GRANT A PERMIT
to ( ► ` �l_. 97
i (Name) 0.�� ��� 9 `t $
the .: / ��((�� ( (A s) �l
to hold temporarily and }4� the body.
. .. . .. . ....
(Underta er or p n having charge of iq se) y
Dated.... 19.6 to (Signed) (Ipta,.emove, or erwise ,,. - 1 {state how])
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to loci 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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