Kroch, Lea Form VS. 61. 8.16.35.50,000 (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH -
OFFICIAL BURIAL (OR REMOVAL) PERMIT
M'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 L& O 1 Registered No....'F/2
% o-�� 74(4 �'
County Town Villag
./. '� or City (If city, give street address)
Name of deceased � �•
Single, married, widowed,
Sex Color or divorced (write the word '` Date of ea h te
d, Si" 19 3C
Age 72— Year �Q Months // y P e
,.,,,,,,., ,/ f� Days Birthplace.. ..�
Cause of Death .
Certificate was signe by. 772A M.D.
Address �7 r-a,... '�/ f'
Place of Burial (or Removal) A' ' . . ... .,r..!!l°' , -*L. -
(If body is to be empotarily hel 11 in later)
Cemetery _...... . . Date of Burial... 31/ 19 3
(If body is to temporarily held, fill in space let )
The Certi Cate 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 sis thereof I HEREBY R T A PERMIT
to 4o` - ,, ' .
ddress)
the to hold temporaril the body.
(Un r ker or per56n having charge of core ) n , remove, or o ise dispose of [state how])
Dated 6i..._.....19...3to (Signed)
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.
S.
O " cd.N> N N v v
T'a� OW
bL 'O i . Q .OA ° d 0 td•• v O U•d OO 4. 0 n u.,,.�.A O v . O O, - cd, y .N O d p.Q O N O U O � .. Ob WV)4 y H > > 1 ._•�fd t'd+' tot
VI 4 Id.., x0 0 ao
V
W yN ° � 83; � 3`. > 00 � z.0v ' „ u :
;450 al
va a, b m > ° . o. A Gai~.� ubt.' vva
y ~ - w 71 4,N a , v. i Oca � vu 0) yQP .v ° vui yG'b a' q YW a OC W i • ''O s,Ar > P '0Gd s.y _pp s, Q O ..+ ' ,O, .. ,, L.„Ypi.
,„ y N I. I. f 04...d 3NP,a ms qX vO v d` .p
.' " • C� " � ; y ^, Q c�.a _q ° «v U ? .
O
a
s
V u e dQ vvn Ow
' A' fcc,3,, O , O Q s.,a, ..d O O O . c 3 .^ A tiw 8.. Otd v u ' e..Q :, .., b0 cd d a5 uy b ❑ w a 1. w
44
4
;das 3 4O G w " Q vp v.c Q. - vv 'a'�j7 a cp•ro ..N•v O bq, vA v3ti Q uvGw° O,dva warmF6, [ < v b ,,p, w ..
fCOu•.�'� v vyawv,.uO gGi ., ti > .r, .„ v u..+• > en s. , Gy'" 3. A•o�W�� 1-4 ti a, . bccd c , p � � a 4' 1+. ' N > OOOT .., O >l d .CVQ m Ad v„. . S ...pp OQ vro A Qa - ti n a t >,> , «.0 QQ., wow4., o , °poti „ y bv z - owlo. « >, _yu � 4 lli:
«'byOvba, . y.0 .. dA_" oo ".- v Q 64+V'O: 4o w ,,2-o° 0> . v , 3WZWW •.•`..S 4 . •,-'c c.•,4.00 .'',. v6.. Od A' o . °o() u . ,;.ag0 ,, . « '° ^du ' a ' y> 'S� OW b , ' °� °p2 iw i ' 3 > d � U °, � o0: . cN pc QXoiA d" .> a 'aR 5a ~ vv ,A';S4yu iW%
03
64
d � � w . w0 IYd dLa0d�2Qv ti -,v•-.00, " �� M O n oo - vvd3v
. , O v 0QAv Z
G a bV 0"O 0 � � 0 �vd °y°5 65 °J0 0 L . 0 . G ) 0 " Utn .0, ^. v 0u ~ . o p4rb •> yv v0.)i o ,,s• •.... •" rW
Ltd 0W o �q wA F i! u p Q O, cu: d .GCv ti A v .gQG^ Q ro ,gp..� - v �AwmO w d.azW •f .9•p10 aQ 0 ca.., v +4 ,, , 00$ ,- +.. cd ,. 00 ,.°, vb _ cv , 0
. °C4 q 6 ac-0 �3. °CG R ar m 4. >=„, vcz ,X40, S, uUwFA mob � Q s.aO ° p F,Cvv ,:.» o wo,uE E 0wa5vs0 ~t«, o ° O
ij
•
5.1 ,TiC v0 4 d 2' � ..0 0d 4 U 0uw >R7 > u ++° -1 C • 1•1... 'Gv r�'. �ua4+ a O* oO g.,o� .0 . ` � u v ,w,c•y,.v "" Q ° 4 . Q0 « ..� . �n` 4.a ,-`` . o,..- •, 4,, r ed O tyt w .� p �H �-1 .ti a.. u $ c5 v65 cd � uvp a b .v• . c0.iHG ZHZ ;+ O « '..'Uv � - 0 --c.LI O �^ �' Qo � °c v-o.4 v a+.. 3po u v ..cdcd caV '" Z '0 cda5Ow°.pt o,c p.Q > •.. <tl U v c .dvW'4 k, 00 W �14 ArJtiW O•'Qu O v „ v .0, > •-• ,✓ cQ Q v ro 0%. ,. L. . ,ti T a+ p .a ' .c1wcd.uG > Q3 s rn i . O m5 v OG t. QbA 1.u30.� Fw °
FIy , s3a ".-c '70 . , a • i,^ Qo ,a u y . O v0 00 0Ad�x aF' .' 0 ° x - y e' �a ° b� ap > a; o a s.b " dYS c „u(,�0 °i � d d
WZF cy � � xrOo ,' > aOO •d ��3 0b U ° ° Z olWctlC0v. a 4•
° O. v 5vO y 30w "* O , +, O O�,c•^'b- p av247roc, uv�1.,E NC' C _ QGgO p, 0.O^ A0.,N.? � Nr EySc.4 Qb.. , Z � '.. y Q c . >• , Q�.» ao .Q Pbvo : v °_ u ° ^ u O. cd4. '" 0 . e, . dV)a za izW a V 'C .� Op '> ~ v ,. Ua, ° a > v Q • ai an d7OW « ;W.7 y ; �' ° u.* Eg +- : a. m• • a0.0u.s. ed � .. F+ •� ., poom �b . « q ° �A. r ° OcuoZuu vc!� w�� bAuaa ,cu �.«
f vs 'O ypV) a ' ! d V .4 u vw ? OU ; , � •-,.S cA tdncd P, pOy O yay> .-, s. ( v '. c Uyt t .4Wa i+. aay be- PO.as,,, o ; s O 4 pQ * � U0 . O vca4' 0v ,. Q'±, mp
cd almaabZ adba tO a . Q vacdu Qti -, `nO .•� cd3 wT., , ai 7.,.On u 7U
> ; v w "9v 'C ti. b uv--" ,n wU y p, uo,pE. gdg °.Ctt~ 74 U = bqvW W d, oQm m. Q v > QvQti O uU'L7,5, cdO.y Ou"O. w vs N 45ca =.• oamp .+ s, v O� as
« F. .0 E •Fm s, v O A A.awO vnQO•> s~ c d m O O O ,cgsd•"'_., go-.„wO•'= P,Q C,, v , G' i .. v *, >4. ca .+ Na to V]^.•.. x a Q-u >,w.� ' cd c 0 Q ,,, t. v ? daa+.O =+, v..P,IS M .. v'7 ~ v Q_ bU� Ou4-.0:C � d ~ aUQQ wuuuN.-A 0.A. ypvt tiMuvbAQ c vvpQ . �vCy � ti vO> � cd �pbA � >,Q ° ""FoeWp+ 0U •
uOW e . O uvu g400vctia-Au•7xv � m ,Q"yQ.° o,c�. vCN cv vw� � 7%.pOx° � >ro,,c,x a, o ..00,,nti: [�w�7� q nc5 d E',7.Q a Om v v. .43 ,y bn Qvg x _..0 0•0 z.W .0 0V10 u .0 0-...... t v0 w =,QC., O o > OwuC.' v^ Q caV) yW wa.) Q v•Ci O P 4 5. v0.,, �"+•,w > Q O Op ii AQ v.r.' O7 O„k id ° v Os «H.bq.Q gp ,r1d•C., I. codO d.0.., N v 0 t,•.,Z s. . 0 P''Cvv Q > mOw O0 .,-A > 'r n' .. AQ'cd am' 0 ay d c.CC bA.-• ' E . 7, � V , ; � a d Z300 ' 0 n, •• a..)•C., > a.) •Z7 Q•,C* v O Q O v Cd GM em 6 'O Q sv,a,.Q s % O v bA .-W y GAz A w� s Q y > od Iw ,., oa.au 0.;. V PMQ « idu 04 ° o °, ga,04 � � : 3A , uz.0 VU, , 00z0
4.
0 OS
a � � , dwG ; o.� ~ " � 0 ° vo' o w .w.o .°a . >Q .,0:0 . , -. o ,- 0; ,~ Mz , . � .50z,� .4A -V 0.0 .. 4>.~ �, 0-;,,-,-, � o sP.r P,v P,P, �... P,a.,.+ .•O.•., 0 0 . ,.A..r 0 d a 0 t.W 0•o tr 0.0 . o
cd