Mumblow, Clara Form VS e1. 6-8-34-50,000 (17-7901)
..y/ NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ffXr 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.
l Dist. Nei CO 5 Registered No.
Town
County Village...O
"27 ?-7,9"
r City (If city,give street a ress)
Name of deceased.... r
Single,married;widowed, �
Sex {� Color r r divorced (write the word):f, Date o Death °�,. ' .. 19...E
Age 6..r' Years 9 Months i Days ` Birthplace / ��nn
Cause of Death z.02` (L "__ 1 ..... .. .........cr"Q•'C-'?s.
Certificate was signed b — • M.D.
Address .�-- ik-- ) .,' - v
Place of Burial (or Removal) r�/.��f }-. ...- .. , a ,
(If body is to be tetnppprarri heskl,fill i pace later) / �
Cemetery— .. - 4 Date or 7.'Burial AL" ' ' �-' ? • 19.c. .19
(If body is to be temporarily} d,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 own the b�alis thereof I HEREBY GRANT A PERMITA 4 !]
(Name) 2 ( F
the to hold temporarily and the body.
(yndertaker or erson haviu a of cc pse) y`% (In r otherwise dispo of[state how))
Date .. -.''c. . 19,:.4.2 (Signed) - • ; :-z-4G2-- C
st
99 Local Registrar
f
This Permit is sufficient for the Removal (and interment or Cremation) of a bodXto any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Per it (VS No. 62) is required.
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