O'Brien, Tomas Form VS. 61. 8-10-35-50,000 (17.1423) - 1
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT '
or 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 Registered No...
Town
County C t 1i e4-a. Village
L L or City (If city, give street address)
Name of deceased..41 t J 4
Single, married, widowed, '
Sex,n44 Color 1-4) or divorced (write the word) 2 " t. sr.( Date of Death. 21 19 A' co
Age. 4 Years Months 5 Days Birth lace
Cause of Death '
Certificate was signed by ......../ . .. ..... . .. M.D.
Address lAr r4 .'"k r 72 — . •
Place of Burial (or Removal)
(If body is to be porarily held, 11 in space later)
Cemetery 4.. ..[s -tf. Viteg4-er Date of Burial.."klit.ay X. 19 3 if
(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 thereof I HEREBY GRANT A PERMITto-Q-1-1404 Areffatersent.„,, '"( .41-4-• O Y
(Name) ,(Address) j
the to hold temporarily and .‘...r:...,..,,,...• the body.
ndertaker or person having charge of corpse) (Inter, remove, or otheyr��iise��dd1spo e of [sta how])
Dated."7-...,�r4-tr� g..?—, 19...E (Signed) .eth.eoree.- �lv
((/% Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local cemet
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
f r�r O y+ q v�U -w N,�-d i. v i. Y w bq+� i v w N O s+^^ N N v w N w N v N w X I.. t. N,O w w
Arb ;-+ ,c.,E-1�j t1t p p v > o cd• _v o u. O O J N 3..°.. o v.4 O O,cd.., c4"aX+ p �y x G v O u 0 O. -0,- o a t
Vi W CO)Z+ at.,, N > G> O L w.y f L 7 t N 3 r y ° N .0 0•3
#1�.f > " q u o ° N ° •� a �, m u v o b43° a, w a o E o °�' 3+ p ` 3Q
W aab m > wN �.. � > a u. ° o . .y s~ t � °' N 0, .,
71
y a .II o+ v s, v y-o y, v'u v v -o 'o o ,;v % v >.� G. v.., E v E t,.-. v+' a' A +'
fN ' t• - o v s v v v ca w v a•-'c7 c,,� v d�/
t.Ci ›ti 4, V L, N (d L' .. Y T".w-y am, v Y 0 N N a, RdI
• V v ' a•'C•N °.o° ° , yN, t,...o E g 6. y 4;
�...,.. _ .3 pZ O Q v0 . vvcdv ..cO(A• O(� pw., � .>. vO ^7` ihHh1
v -0 .o AwZ -• O70ti �. at bAoy•-• oy u s OG^d , c—.., uv > 6.0 -...)•O cd�-O 3vcdvwCO "..., 00N � � v � 0b�s° ° �y� c, � �} ° ff ° a o �� sAO p� + ° bum �. w ° N oca oo , u �b „ >,^, Y :a, av ' >' ..7) ~ 3' o CLN t, O•�y C v v'['•a,O•� ? 8 . 4
zZ . M �.. ,1-3 ET8-n000 ,-. ..2 , 8u �`„ a. EEa, : ..,u, '".n.-oau, u", ° ay-E' aoui,.,,"7.a o� °" h,p
.a 0 d H,b v s. O.-, V y v y v • s.. v a' 0 O.0 to 0 ''' p w N.b > .a -0 .;
-0 V VI N a, a, N Q,�'`C�J v -� .c G.,N". ° u « a, �,..,'E 8 °... o ° — fi a, t0ggi :;
"�w^ v� .mow �+f�� p,y ..d•3,O G,. y g Cd cl v c) v 'i, u '0 ro ti u.-. m y bC O t~ a, v v �O '. v cvi ti.+'.r' • O
k.l \u O "1 L, N u v Ld M y °y o g v b0 cd 73 �,.'• v " G�y •i„ N a yq, 8
®a< kk d t. ti O W [-' aR 5 6. 9,o T u. ,o'o N ..w° U N- =X. O.,.?„o ➢S p..y ,., >,> ai•yr", .6 y •1•,,,..,cd.`.�, fd L) ."Q om-+w CL Ou',s LLL rail
i
t!1 k 0 oA W <•c o Ni..0 u v .°M 3 ac,a r °� N N,p.do o 0 >,+' t. vid•b 3 vv O >,O v �i Z t'.
a/W - -,.,V 3' ti a,Z O w.'o. 5 y u v v a, N'o Ea; cC u v.L' �- L,^o v ,.' v v Y i.w'L7 O ," bO.0 N Fr Lei O
n". vH .Fa o '..- a ,..o , oYcu� N,, a,„ ..y v. aG o d � " uotd �. � >. o
LLIE1 o o04uw vs pQOi v C sys oy . " fix V0 u ' ^oy uoN O QdW y
C' W a 1 .00O04o '-. .-• >, rt^.' w CH-1 V O s... -r v w, cd w cd00 u.b V N0A.7 W a
rr�v �xadZ :,.a 1°_ a.c� e~ 3.c 3N:aa.-to—..o u '. ov0 O.y'.., p p aa'" Nv � a
Fri a N�r 0 ,.0 v O d t, U v 4, >. N b'i N O G,° •3. v v >~.Y >-' (,,u �" C N y ict O 6....v O o
Q O W cd-0 sv' A.4' i, v > v RTJ s, O•'O U•.-.•% O �^ a' ^o V Ct.0 u�' 9 0 V O o cd cd F"1-o ...
� ti
®rUc�/i) ; �`" fl ;i
� Ji19Ii
w 0 u v�.ux..0 E a3, a r cl eddidN•0 a,l = NO cd cd cd i s. S b .o-C v p.C >,,,yd • . v ..-. a, u �..=a' .-Z d cdu a,>,.ty N ed v L > s _v 4 C v, C�>w a+ O sO bq4 °�, c ° mac mom ° •� ° a.,Ce.7,u v to u,b 7• a' " ad p .,0 > a;; ....o"o`) ° at U 0 ti °.--, PI v N id ° c' C,3 °' F a+
W • G o 3CY. t. O° N d b Or a d �A Cal'-0 y O vw O o rt i O°J ccdd u 00 O v•� cd a>i.° N v•^.4 y. CY.w 'b
w C.w Lg.'. Wq O v O,, .v, ." cd.-� cd O `•, cn y u T1.0 O 0 O N d u bb 'N. cd m 'v. N TJ m ao,y 0 N W O C4. L•.
CAQ nt+� 0... ( , ,..-,.[ N Pu-o..,•oroo > ,. � oN d� � Iuv^;.SG � . krn ou0o. o u Q 7
w . 8 a0+ E.y V.-,ct O 0 v.-. v bQ I, p ?4 y • a, (d ed, N Q) 0..r (.'.� N N'o•0
r1.1a't N '' a.•o u o z P� bq o: of u u ❑..., >,.-, N O a a o 4. 0
�g Z d Zw st ow m '. u N * v 0 � " 0 is o o 0 C^ u.� o v Z W d
0 w • ~ i a7 y C/� �i O 3 °y '. > u v w i. b ..o... d >'v O ° u N u Tf.' cd ar
{� W 9 'n o-�+ v �- o a+ v ..'.' A m•b..0 y ai z u s, bq= "O.a a' u] �"y..�.
Iy r. \,\`5 u l'LT c w F.O cd cd" s. N ° u '°. cd Cd., p - H u.., b= t,. a 1d..,A 02 u-, bA O Z N 0 v•v, '�✓`*..0 v ',1`." ai a i m s > x,y v,., — aJ O U.. c9 y V t,
s W 8V :+ ybo_ ao. � o� ` °� � � a� u °u ooc' > `wd � u u a ° � o � t��: �Qa°'
y S a, -d a) Q o RS..N, t+. a, MCI -0 (w^ .1. t, .� p y cd N• y vi•'t7 N N U.•� a, RS R
'Ga 5 >F v w C v -.., , 3 N u a w ai ni....0...... 0 ti 0 a t,.
F Q '. t....'� a)^' N W a, .Si V' .F.) U L, F.' 'Ly
do tx aG u p > cdN O p x >~ = .a
WW tt.O� �.0 a°1+ N•- ... NL voa Ovv0-
- ... OCN 0y 00 dcdw ''nn Ncd1d NOQ'-'. U .. cd0vy On ,,
2.g s. F. u x• i N. .'OF' p p a' t O'? ti d O o ,n N O ° cd d w0 i LA A 6 • VI ...• y w cd—Z "T. ro
m py-...� .o � m � ° � Ntiuo as a..',n '" i, ua.. ,n u ub a'" en o..0 «F.....111
w44 ,CE 4;4 X , o,$) Z•inw.Cuv ,n• .z: '.A... v21NM.44i Ve vcd+' t. a' A , ed •v ye~ N ctla°, cdC,-, � uy0::
Ct) " oW ?.. Li] a) td— , ,dp0u'izat', r10...,.y3uvcoc°,-7vv ,,, >, ,g o0co+ 3-[ ° a au ° ° •-, •-°..,+' > ca' g0F'aed m
O C1, 08 4 p,N N .4 N.., a, O o N a 2 Q `L' (d a Q'y. Q(d.M+' ar N—�.,.d :.c a ed p cd R'-, ld... '"•-�;
� `a">s. .o cal.; N u o-V (1,o u u+ ,Q • - 3.0 ,11 ..-, bn•,V 00 > ow o„,u .�-G 0 y.W..0. q
0v.)0 u a. vi •7.E s°'b i oo acew u y 1.., o• u.. o N ..o I"
0 o Az°C ° d t•y °'+'� o'ft o.x ..., as O0 a 0,,,"'V3 ca �~•G
Qa ✓' ..V. h O L,'..'' 0. a, N �.' N-. ° CZ,' '7,"-0 O () Q aJ «i v (d.b Q. ,-b•. t..i•,i N '! as W co
i d p t� u O,� v ° y '`n �.c..vo v ' cn rg g•p v'M 0.) o 0 o�v cd ca) a'»' N °'ca,a'.fl � '. s. •b a�i , by G'v '�"�a
M v d
yta.0 z ooQ ctn 0 0 c 1-,4•� p � E.N.'>_ °;d. w',p3:a:, O.a a.-u u 'v.c' T,.. 'a, c,.......N^o ct u ...C. O a~i--•31,1 0
t%a T H d w �j '••y Q. ti a6, ai O .� O w ......
,C eNi Y '.. a�i O O t, v ~ v xi '� sv, O.o'GOZ•� ind O
`.'CA ell O 3.El w N O >`i•. 3 3 O i. 3 04 4r a N a Q, u.., a G,�' N•o.,. ° O N 1.P`r O ed.O °