Ingalls, Daniel NEW FORK 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 an9 acceptance of a CORRECT AND COMPLETE CERTIFICATE
OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No Li ( Registered No Q
Town, J
County Village., 3 iti
• ��y (If city, give street address)
Na e,of deceased
Se ;l�ygle, married, widowed, /
G � Color. Y divorced (write the �yafd) .... Date o Death'
.... • 19 {O
Age ,. 6.. Years Months Days II. Birthplace.
Cause of DeathtvJDL. J. .i .... .
Certificate was signed by:.. ;.a:-.-/ M. D.
Address
Place of Burial (o Removal) (,CAC.,..
(If body is to be tempor -i held, fill ilt_spa ater)
Cemetery dam- -4_ Date of Burial f G 19.5 6,
(If body is to be temporarily held, fill in space later) _
The Certificate of Death containing the above stated particulars, having been preset]{;d 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 Rec rd with the above stated Registered
Number, and on thebasis thereof I HEREBY ANT aA� P RMIT
to ' ' "'�`�'�-, �7r7 . . (---j
( ame _ d res
the o�. to hold temporarily and the body:
Pit*- r or per?having cha3 Coorpse) (Int ove, or e ' d' se of Est w]).
Dated \. I 1.9 ( ' (Signed) ..may.,.. ...
oca egistrar
ThibPermit is sufficient for the Removal (and Interment or Cremation) o a ody t any part of the State (subject to local ceme-
tery or er regulations),unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
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