Selleck, Mary NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mgr This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (To,vn,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTI•FICATE OF
DEATH, LEGIBLY WRITTEN.a� IN DURABLE BLACK INK.
Dist. No. .s7Registered No.
Town ,
County 7 Village
Nanpf deceased
may, (If city, i e street address)
• Sin married, widowed, • �
Se�Color i er divorced (write y e word Date of Death ram '7 .�/— 19 6,
Age 2.6 Years 2— Month s Days Birth lace
Cause of Death
Certificate was signed by r , M.D.
Address ��` -f'
d y��,, U
Place of Burial or Removal) • e - - �,
(If body is to be arily h jfll in.space later) '��,�
Cemetery �1. -e-- l/ — Date of Burial.2 ' 7,4 19 C
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated articulars, 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 the basis hereof I HEREBY GRANT A PERMIT
to
r G'
(Name) (Add
the.... .. to hold temporarily and the body.
( err ker or perk)!!! having charge of pae) (Inter, e move or o env dispose of [state how])
Dated ( v, , 190 (Signed)....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a ody 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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