Miner, Albert Form VS. ol. 8-16-35.50,000 (17-1423)
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 WRITTEN IN DURABLE BLACK INK.
Dist. No.S6 6V Registered No./ /�
Town �h
County G7G�
Village /�% -�. :..
or City (If city, give street address)
Name of deceased ,A
Single, married, widowed, _ /Sex.2 Color or divorced (write the word)... Date o Death.... . { ,'i 1936
Age ` Years Months Days Birthplace�'�� /V.
Cause of Death �t
1I ,.
Certificate was signed by F M.ro
Address - b-v-
Place of Burial (or Removal) i 774/.
(If body is to btemp ily eld, fill in sp later
Cemetery Date of Burial /7../ 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 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
/fthereof
I HEREBY GRANT A PERMIT
to
es
me) iK'C'�S �((Add�ress)a the body.
fi�tt
the to hold temporarily
(Undertaker o erson havingarge of cor e) n remov or erwise dispose of [state how])
Dated ( ,!,/ 19 3,. (Signed)
Local Registrar
This Perm 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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