Haynes, Thomas form VS 61. 1•23-s -25,OSO(19•5154)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. Registered No.
/� Town 2/
County.. cep+-c. /(
/� • (If city ve street address)
Name of deceased ,4.) ,C,a"2 j
`.t e Single,married,widowed, 1 e • 'r
Sex Color. .. divorced (write the word)...... Daof Death 19 v c
Age ,....3 Year /,1 Months l 0 pays Birthplace "f"4 / 7' .
Cause of Death 0-34- ),--�����V ....... -
Certificate was signed by '"�'?2 .,7/i
. ... � M.D.
Address f
r...; ' 1--
Place of Bur' �or Remov �) %r w'2
(If body is to be arily held,flf} sy'ace later) "�
Cemetery...... --'V — Date of Burial i 2, 19 ,. '0'
(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 a sis therpAt I EFREBY GRANT A PERMIT /y,
t0 / // e"7 •
{
(Name) • s (Address)
the to hold temporarily 'nd the body.
( derta r pers rfraving charge of e) (Inter,re o othe w' a d' ose of[state how]).
Dated... , v 19 (Signed) ez `
ocal Registrar ./'
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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