Mc Echeron, George orm vs 61. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr 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 W IITTEN IN DURABLE BLACK INK.
•
Dist. No-2 -6� l L____,__s_-/
Registered No.
Town
County Village.:.
�/- (If city,give street address)
jer
Name of deceased - A& .. ✓!../.••� l'�l 11�lzYt/
/Single,m ried,widowed,
Sex.. .. ..1...Color L%ft '. r divorc d (write the word)0.4, Date of Death ‘ 19 3:(
Age .., Years Months Days Birthplace..!• f.
Cause of Death eLt�} . ._.... /
Certificate was signed by �f.-\i y , M.D.
Address / • • -' ` �
Place of Burial (or Removal) ,' .'.! .14i / ��h . .
(If body is to be temporarily held,fill in space later) //
Cemetery • L....t. -Date of Burial L.O 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 e, 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 b sis--tKereo I HEREBY GRANT A PERMIT
/ � 9 at -2-
to t ! ,
Addr--_, L%�
the.........e ... to hold temporarily and .:2...1 the body.
(U rtaker or person avyy}}g charge of rp (Int r,•iir erwise dispose of[state how))
Dated � �.. - J Li 19 .L (Signed)/..f.."1' t....
L_s cal Registrar
This Permit is fficient for the Removal (and Interment or Cremation��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 T sit Permit (VS No. 62) is required.
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