Dudley, Joseph Form VS. 61. 8-16.35-50,000 (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH .
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lllir 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...(, 6A... .. Registered No...././C
County .2 Town /� ��� -,A
i� W Village y � - £ �'� -►ti ` �.•
./�
or City (If city, give street address)
Name of deceased ori .._...... -.A..
,,, _' Single, married, widow - Q
Sex 1 Color. . ..or divorced (write the word)' +-� Date of eath..42-74.2/ 0 19,E 6Age La...1" Years Months ././ Days Birtp�lace..
Cause of Death .. ...e /P7.4. :r .
r... .. »... � ,
Certificate was signed by r M D
Address ... .,.
Place of Burial (or Removal) �I'tsl.2i... ..1 L(14 ,tom ,
(If body is to bet arily a 11 ' space later)
Cemetery Date of Burial U 19....31i
(If body is to be temporarily hel , 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 asis thereo I HEREB RAN_T A PERMIT f�,,
to ) 1i64/�-- Z�'W�j ?-4WIR_1,le ss) fit....~�
the to hold temporarily n the body.
(Und ker or pets having charge of c rp ) , e , or otherwise: su
[state how])
Dated (Signed)
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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