Prescott, George Form VS. 61. 8-16.3 5.50,000 (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
NW 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, LEG BLY WRITTEN IN DURABLE BLACK INK.
Dist. No..x`1 7./A• 470 Registered No.
Tuvvi= • 7 i/ `
Village 7 y�l " r.
County (If city, give street address)
Name of deceased 6 R
ngle, married, widow , , 19z3..�a
Sex.. C.�r• Color L or divorced (write the word).... e_,..Date of Death .-
Age a.�'l Years ( Months 7 Days Birthplace
Cause of Death..... .. .. .. .. vf-Lidr—
•
Certificate was signed by eis - g M.D.
Address -�7�. .
Place of Burial (or Removal) ,/Q4-14,"' ••••
(II 1�y is to be �r�a ay held 1 in space later) 19, `� •
Cem'�tery am_..... Date of �urlaJte� •••-
L Air
(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 o e basis thereof I HEREBY GRANT A PERMIT -
to i►/ii ddress)
.:: ame) f
(N
sOr4i--ga-P41/r(4'd frt-
the
to hold temporarily and the lay.
(. �mak_er or person having charge of corpLse) �n (I ter, remgye: ormirerwis`t e�disposee o��f [state how])
Dated.�..,...4r� 19z3 (Signed),.... . °"" Local Registrar' 9
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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