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Moore, George Form VS. 61. 8-16-35-50,000 (17-1423) NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT "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, LEGIBLLY WRITTEN IN DURABLE BLACK INK. Dist. No. S' Q..! Registered N 1---, , / - T 1r , �LL.t.--2—, cy County �t�,� V-�llag2...�'', d or City (� city, give street ad ess) Name of deceased `-'� ' �_ Single married, widowed, Sep(....O Colour divorced (write the word) Da e f Death .1" t.6 194,14 Age 81 Years .3 Months All-, Days Birthplac ••• ••• ••• •• Cause of Death p •,.. .. 1."--"tom "" . ... . Certificate was signed by...,...r7. ._ Qt..,., M.D. Address 1 (or Removal)....,e,d4-....-L .4..�c.. �'t` • (If body is to be poran y held, fill in space later / e/ 193 Cemetery ..e... v Date of Burial.. ... ,.�� • ! (If body is to be temporarily held, fill ins ce 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 ('e basis thereof I HEREBY GRANT A PERMIT i , e — I t . to ,/f//) Name)the to hold temporar•1,y andSi.6.4...e.fr(Addres the ody. (Uner or person hay. charge of c s } f (Inter, remove, other spose of [w' a di ate bowl) Dated 1947 (Signed) Local Registrar This Permit is sufficient for the Removal (and Interment or Cremation) o a b to any art of the State (subject to local cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit S No. 62) is required. 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