Huntington, Martha Form VS. 61. 13-16-3,-)U,0UU (1/-14L3)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Elir 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 WRIIN IN DURABLE BLACK INK.
Dist. No ii--.0 a / cR:;* ered No. /ff -
,z
,
Town ,
County...' Village ,.--- 0---a'
or .ty,-
(If city, give street address)
Name of deceased 1/7177,-"a7Z%--.
eif./1/2a vpitecit:, Single, married, widowed,
),..
S A, Color. or divorced (write the word)-Gki.,724-ki,-e-------' Da of Deat ..__,1,9 3‘
A /y Ye 7 Months I, Da7 )&ceth Birthplace. 4;4114Z.7%
Cause of Death _
Certificate was signed by
CO2 M.D.
Address -
Place of Bil 1 (or Removal)...
(If body is t emporar hel 1 n space latOot V.VA t
Cemetery. Date,of Burial 19
(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 a pted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on e basis thereof I HE Y G ANT A PERMIT
to...
(Na ) (Address)
the to hold temporal/pj2 the body.
(Under er ills° hay,ing charge of corpse) (I r, r e r therwise dis e f [state how])
Dated 5fg. 1 9 (Signed)
Local Registrar
This Permit is su icient 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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