Hermance, Baby boy rorm Va. 01.. 8 1e-57-70,VUU 11/-i SZ )
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gi/fr 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...�6 O I yigistered No 3 r
9, Town / / _ �,
County !� 'e"�`— Village / fr "` ,r
/��f !/ M1 �// or City (If city, give street address)
Name of deceased 7 PA-
Si gle, married, widowed,
Sex Color or divorced (write the word)..��E�'' Date of Death.. y// 19 4.
Age — Years Mo the Days Birthplace .., 7/�,
Cause of Death r� e' `""c-c_
Certificate was signed y 24 M.D.
Address 4---11-"" -71"
Place of Buie (695 Removal) 97— 1 ' "'�"' a
(If body is to be -rlarel�y he 1l ins e 1 ) /
Cemetery '�f� G � -_� Date of Burial Z/ 19 3 �+
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been present 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 a basis ere,,0 I EBY GRANT A PERMIT �,/
to � (a/ot-a.--• —/ 71- y,
Nam or / (Address)
the to hold tempor. i a,bt ' the body.
(U rtake or pers,4 haling charge of corp o) emove, o • -- '-e :'spose of [state how])
Dated F. f 19D& (Signe O
Local 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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