Hulpin, Samuel NEW YORK STATE DEPARTMENT OF HEALTH i
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ilr This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Tam.
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGI1ILY WRITTEN IN DURABLE BLACK INK.
Dist. No. Registered
�� R tared No. _,.......................
Town
County .. _.._. . . Village.._...._....
�/ Or City In raw iw w stre address)
Name of deceased. G% ___ `
Sexa��1��' - / ////����• Single, married, widowed, •
'�+L.LS._.Color. Y._.�__.or divorced (write the word). .___Date of D• tit ._........_. _ ...2.1C-.19 t.
g .._......Day Birthplace_— ..._._..__ s?n .___.._._. ...._..
A e_.... l/_ ._....Years...._._. \Itmths
•
ause of cash. �_� ?
Certificate was signed by _...._._. . 4(.._._ �.1._'—._._._. _...._.._._._._ ___—.____ ._— ._._.M.D
Address.---__... !'+� _._._._._.._._.....--.--..-.-.----._._._.._...
- ,fie
Place of Burial (or Removal) ..... �.GGc_.._.__........_._._.__._
(If body is to be toqporerely hold. 6I in >pae I ter•I •�
Cemetery_y{��/{ "y; �1 � - Nett
(If body is to bet temporarily held.ill in later) - _--"`- Uate of Burial_ ._._._._.a ._._...._.__—I9�..T
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 basis thereof I HEREBY GRANT A PERMITto .Weft-d--frfretess-7fite-e-e-set.4.- �n �
(Name)
l 1
- —
tlte._.._._......._............_.._._...._._.._._. _..._...._. ...._...._....._...._._......___. h�porarily anti. —_ _.the body.
to esker or having Marge of< ))rear. remora. or °then .of I ato ])
Dated._ _._.._......._.__._19..� !gm �y���-..Ql_SeS ... ..
I Lard RWsv mo •` t.
This emit 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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