Mead, Bleeker NEW YORK STATE DEPARTMENT OF HEALTH •
OFFICIAL BURIAL (OR REMOVAL) PERMIT
esr 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 CERTI•FICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. e e
Dist. No...171/ :0 Registered No
Town
County /��*��'L' .- Village r
or City (If city, give treet address)
•
Nam of deceased
C ' , Single, married, widowed,
S .. .. ..Color ,1 or divorced (write the word) Date of De 1Q1
Age 7Y Months.... [ D Birthplace
I
A
Cause of Death x�
Certificate was sig by . .. ....,. / M.D
41. Address r -_ it •
Place of Burial (or Removal) `.. ".. ,:eet.+ aiw✓
(If body is to b mporar' eld�,�fi�L 'n space latezj., I. ,
Cemetery � � 7rl••w � x.. - Date of Burials/ / 7 19 ...0
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated pa iculars, having been presented to me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
IL 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 GRANT A PERMIT o
to ..0 /0..a/C,,:GLVt- X a
s
(Name) (Address)
the to hold temporarily d ' the body.
(Und to r or pers 7ing charge of cor se)Dated , 6 42 19 % . (Signed)
• Local Registr
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.
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