Saville, Myron r..rm ♦o. oa. o-ao.5,-,U,UVU (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT E
VW'This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration D Cr
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No ��` b 7, Re 'stared No
Town
County
Village
�" lr�V"pTi (If city, give street address)
Name of deceased � `- C J •
Q� • Ingle, married, widowed, `
Sex �_ b lor.. ..or divorced (write the word) w�( 'wt-c-�tr Date of Death...�. / $ 19 34
Age g 5 Years.... L Months Y Days )4�, f� y irthplace ^�
Cause of Death Cf—(-- " 'ems ' ��
Certificate was signed by 17 W • M.D.
Address _t l_1 r tiet, - -77 `4 i -4,v 764-1-- 4
fL..........._..,..
Place of Burial (or Removal) -'.,�... .
(If body is to be temporarily held, fill in space later)Ce
is Date of Burial t� r' 19... �.
(IfIf body
dy 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 on the basis thereof I HEREBY GRANT A PERMIT
to w / G"L /. a •�. 'cuspQ-e 1
Name) (Addy
the to hold tempo ily and the body.
(U ertake or person having charge of corp le)
( t r, re v r pose of [stat ow
Dated fiP 19...3.4 (Signed). .. .... ...
cal Registrar
This Permit is sufficient for the Removal (and Interment or Cremati n) of a body to any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which c se a Transit Permit (VS No. 62) is required.
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