Killmer, Clara NEW YORK STATE DEPARTMENT OF HEALTH -
OFFICIAL BURIAL (OR REMOVAL) PERMIT a
This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration D 't,'
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFI
DEATH, LEGIBBLY WRITTEN IN DURABLE BLACK INK.Dist. No. •-r?'a( Registered No.....-./3
�'7,�� Town /,�- / ���_ 2�.,` �j
County ./.!fit Village z � ��' t �i�`'�"�� ! `"""'••,r�
or City (If city, give street address)
Name of deceased 4"44V1--44-- ins.'.
Single, married, widowed,
Sex. Color or divorced (write the word) Date of Death.. r�"e7 el 19 34
Age Ye s '�Month Days Birthplace "/ ri- -
•
Cause of Death
Certificate was signed by N.- M.D.
Address 1 1j
• Y1
Place of Burial (or Removal)...7• .. ....t!f/ �r'/..! '/.
(If body is to be templiarj.ly heldtfik in space la
Cemetery /.�2.- '_. r'44./ Date.of Burial liZA-1"--4--- 2- 3' 19. 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 thereof I HEREBY GRANT A PERMIT �`�j Y.
to 1�yt ,' /
ess)
the L •• ... ¢- — to hold temporarily n ... the body.
(Und ker or person ha ing�charge of a p ) ve, or otherwis ose of [state how])
Dated 1.9 (�a (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is r •
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