Lampon, Jerome NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Bern.
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIpY�LV IN DURABLE BLACK INK.
Dist. No. C . _......_., Registered No..._._.._._....._..._.__..
County. Town
orCity (If city. give sttem address
Name of deceased.__ _ . ._�. r._f..r_.__.__.
O Ingle, married, widowed,
Sex_ Color_.LLCR r divorced (write the word). el e.._._Date Deat 192.7
Age._...._..._._.Year._.__.._._...._. ._..\ nths_._._._2..____ s Birthplace. __
Cause of Death.._._.__
Certificate was signed by......_._._.__._.. ._ ... —A.'___.__..._.F3.r&:azu(. .M.D
...._._._ .__..__._.�—._.___.___.___
Address_.�...._._...._ _._- .ALA.. �j��....._._...._.. ...J..� /,� _.__...-
Place of Burial (or Removal)._..._._._...._........_.� __.' 4�- T__.
(I( bode is to be temporarily hold. fill in pose lam/
t Cemetery _ _.t_.F.__.._.__._._t-4._.......__Dateof Burial 2 _____ ___19,2_t
'II( body is to temporarilybe temporarily held, IIllwo in space I )
The Certificate of Death containing the above stated particulars, having been presented to me, after careful examina-
pion, 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 o the basis r f I HEREBY� GRANT A PERMIT
to _ _..__._i_._t .: ..._._..__._._.._.._.. _IYi ci 1<t_.
' ' C
the..__.! 1-,y _ ___.___._..__._._._....___to hold temporarily ..._.___ ._ _._t _. .-. _. _.-____the body.
tCirQetulur se estson Heists Aug.t a cn�" emo or eth Lecedigose of Isute bawl)
Dal etl_.._f..:..Z./r: {. 19_..c).. / (Sips �✓
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pan 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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