Jackson, Leroy ... ... ...
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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. ill
Dist. No.....f 3 4 3 fill Registered No........20,__.___.,‘
.................... ._. .
'n -� p Tow
County __1 ej`' taL...__..__._..__.........._. t �_ -A
.
��) e /. V.,---i.., arve 't`fe
Name of deceased____ _f_•�L.¶. i� .._.___.__._...._._._..........._
''}--Single married, !r.�;
Sex___2?ti_.Color.__.�Scor divorce te •r • word Date of Deathfrn`••••• 1 19.E
Age__._L_�_Years—__. _..Month .� __ _.. Days Birth lace___....__._....__.__..__..___._._._._._____._._.__.-.
Cause of Death ____- .._.c i� ir��ws._� _ ��2'! .__._•__._.__—___._..-------.__.___.
Certificate was signed by. i • M.D
..........
•
Address..._____........__..1 ........_.._.... _._. .-._._......�.. .. • _.__._._.._._...._.._..
/ i
Placeof Burial (or Remo a ._._._.__..._.......__._._........_..__._....__._.__....._...._.._-•--.---._.__........_._........_.
(If body is to be temporar.held. 1 in space tgrrl I
Cemetery__ c...._.... ..__._._._._.x._._.____...__._._.._._ __—Date of Burial ____.19-._.-_
III body is to be temporanly held. All space later)
The Certificate of Death containing the above stated particulars, haying 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 ba 's� thereof I HREB GERl�1 / Ct0�
p�� tN f� Q ee"'
the __ .__....____.__..._._._..__._. .__..__...__._to hold temporarily and µ^ _ ._the body.
(U ery►�or person habilchsrrr of corps, (In . or othsnsts ciew of bawl)
Dated__.( SLs�r...'___c_.Y.__...._..19_ 7 (Signed)...._._...._._ fail._:_._._ ___. _._._......_.,...
Kral Regina:
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pan of the State (subject to I cemetery
or other regiiations), unless remora! is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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