Reed, Patrick Form VS. 61. 8-16-35.50,000 (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ber 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.... �O1 3 Registered No...7 -
County a�i ._ Town �],�
Village./& w 6 .1'�M t �A !: Z l..l:...Y.
p �Q or City (If city, give street address)
Name of deceased .r���f� � "�^
Gar . Single, married, widowed, ry
Sex . -' ' +"��
... . .. ... Color r divorced (write the word //
Date of Death....l�� 19S'P
Age 731 Years!' 0 ,....Months /Z Days irthplace
Cause of Death:A% {.:/•
Certificate was signed b ,.
a
Address... M.D.
10
Place of Burial (or Removal) `41-401—. i -
(If body is to b t po he , fill in space lath• , `
Cemetery4 /�y
(If body is to be tempora ily held, fill in space later) Date of Burlal...� / v./ 19X
The Certificate of Death containing the above sta d 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 si hrf I HEREBY GRANT A PERMIT
to / ` 'q--"
)
Address f
the to hold temporarily a(Un ker orperso� avi charge of corpse) the the body.
or °them' se of [state how])Dated .. 2 1.9.3 . (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation) of a bodyy to an Local Registrar
or other regulations), unless removal is by common carrier, in which case a Transit Permit No. 62) isf the Staer uredt to local cemetery
equired.
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