Pettit, James C a,iRl YJ. Ol.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
our 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. / a "3-tAell WI " Registered No
Town 7
County .. fx'�'y `'illage....�`f 7�*�i ell- 0 ."
(If city,City give street address)
Name of decease radCoe cZ• ._.._a .. .: ` 4,. ••.. ,�
Single, married, widowed, /(�G� / Date of eath P 19 G
Sex.... Co or VU or divorced (write the word) kV
Age .. Y s ( ° Months l y D s Birthplace . . r _ .. ./...l..G!
Cause of Death (/ .... .... .. .fir
Certificate was signed b ...'!tl.. .... -, .. + .(.T ,� eefi ... M.D.
Address ...r-
7
Place of Burial (or Removal) <<�
(If body is to be tempora'ly held, fill in spaces}ter,), �,
Cemetery �'11 G�.v�J Date of Burial ... `C- ./ 19 3 C
(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,
ande basis thereof I HEREBY RANT A PERMIT
to LA-A--:c 61A"- %- C.31 �:�- .�✓ �/ t��. 4-
r) (Nam ) ddr
the ��rr4r r GCS to hold temporarily and the body.
(Undertaker or person having charge of corpse) (Inter, re�A , otherwise 'spore of (state how))
i
Dated Set. ..../...g 193..1it (Signed) `... _
Local R
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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