Seaman, Hyman rorm va. o1. 6-16-35-50,000 (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
NIF`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 WRI t 1'bN IN DURABLE BLACK INK.
Dist. No.. J.6 0 1 Re 'stered No. /-5
• Town
County -4- Village.... ./� 0 ,,.*(4 2/ " �
(If city, give street address)
�J or City
Name of deceased Q��-
��/.�� Single, married, widowed,
Sex,% Color 4'V!'7-'t or divorced (write the word)J NI Date of Death., ' /71 19 36
Age Yea s.. ..5— Months 6, Days Birthplace (/
Cause of Death.�,�� '`-c t "ilgo"^- YG2��zuia^- 1 -C,
Certificate was signed by M.D.1h' t-efrli...
Address 11 ' '/
Place of Burial (or Removal) )a Ir vt?-�-�ecrw, ',, • g.
(If body is to be emporar(ly h'id,el in ter)
Cemetery Date of Burial / 19.S3.6
(If body is to 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 t basis there4, BYGRE RANT A PERMIT = // �j
to . f, it 1-
�! t; � '/
e) �i7^i7 / ress)
the to hold temporarily and the body.
(Undertaker person having charge of core e) ove, or o 'e dispose of [state how])
Dated ...17 19.,5c- (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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