Richardson, Alice Form VS. 61. 8-16.35.50,000 (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. \-5-6 0 iRegistered N ....L
e I
County V111ag
L�/ ' .' wrr ��'�
-' Village,- ,
Or Clty� (If city, give street addr as) ..
Name ofdeceased
��/lr� Single, married, widowed,
Sex Color.... .... or divorced (write the word)
�� C Date f Death....0/ `5- 19 .
Age Y rs --� .Months 3B1Aplace....
Cause of Death - .
6.7eLiiii.. ( Y
... .. .. ... . .
Certificate was signed by .!, •• • ..
c�:,2 r/ _ ._..,.... .. .. ... M.D.
Address V t % -
Place of Buria °`(or Removal) ey�
7.6,,,,,
(If body is to bet pyfarily d, i s e later) •••••• ••d••••-"'
Cemetery..... ,,,C` �•„ Date of Burial, a-,(2-„�`"�•� 193.‘
(If body is to e temporarily held,fill in space later) /J vim'—
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 t thejof I HEREBY GRANT A PERMIT /
C,l, re;c&72„) .6
, `79.4,5,9
the to hold temporarily
)
� ) the body.
(Undgataker or person-having charge of c se "
Dated 19 v , or othe ose ofT'state how])
,..:'. (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation) of a bodyto anyLocalh Registrar
or other regulations), part of the State (subjectqd to local cemetery
unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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