Kennedy, Georgiana Form VS. 61. 6-16.3.5-50,000 (17.1423)
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. �2.- ...0 i Regi eyed No. / ? ?
-�/ '
County l/Ll. .. To
... wnVillage .7
.
or C. If city, give street address)
Name oeceased
v Zti—1�- )Ingle, 1 rried, widowed, /
Sex..:.." Color r divorced (write h word) Date of Death -�� �7 19S
Age Yea - 3 Mo hs. Day Bir place .............
Cause of De th .1......
Certificate was signed by s E M.D.
Address
Place of Burial or Removal) " ..,. .. .
(If body is to be to r held, fill in space la -C�
Cemetery .... . .... .. .. . . ... .
.. .. . . ... .. Date of Burial .......�1d 4 cr- f 19...a.6
(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 on the basis here I HE EB GRANT A PERMIT 1� �,
to 7
0 1rt1
d ess)
the to hold tempora ' and ... he body.
n person halt c rge of co s ` seamy tt or o se jsg ate how
Dated . 19.. 6, (Signed) � _
Local Registrar
This Permit is su icient for the Removal (and Interment or Crematio f y to a part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a T ansit Permit (VS No. 62) is required.
z}- Ott.
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