Riley, Florence Form VS. 61. 8.16-35.50,000 (17.1423) 'c/ v' -
NEW YORK STATE DEPARTMENT OF HEALTH L
OFFICIAL BURIAL (OR REMOVAL) PERMIT \
iiiir 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 CERTI•FICATE OF .Z
DEATH, LEGIBI, I ,TTBN IN DURABLE BLACK INK. s**4
Dist. No i kt /% Registered No.
County 1 ,y
G or , (If city, give street addr V
Q
Name of deceased - ' -C �
N Single, married, widowed, '� t //
Sex Color \/" or divorced (write the� word).. l Da e of each �'' � 19... ..l9
Age [7 Years a lonths ,t Day Birthplace tip`•
Cause of Death 1• "
was signed byQ,c-""� !� - `�', D.
Certificate g / u-- w7� / Z
Address t /` /
Place of Burial (or Removal) .a4,t -- -cti z' / L
(If body is to be temporarily held, fill in space later) /
Cemetery L. f A Date of Burial 07" c Y.. 19
(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 as pted the sa • s r registration, have recorded it in my Local Record with the above stated Registered Number,
and on th basis }1ereof. - _E�BY ANT A PERMIT
to
Name) ! (Ad s)
the (ZAAA '% to hold temporaril and� the body.
( er ker or perso av' g charge of core) jXln emove or otherwise dispose of [state how])
Dated ••• 19 t) (Signed) '''�//./-.
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 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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