Swan, Susie 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. ,rCo.(/, �j /l �Reegiistered/No.3/
VillageTown .C5/J 7 4 /6 /-",/,
y
County or City (If city, give street address)
Name of deceased —�L `--
/ 1-J Single, married, widowed, p
Sex �Ge Color �!u or divorced (write the word)���w `e—� Date of Death G r....19. G
Age f 7 Y ars /./ Months f 2 - Days Birthplace. /••h• '
Cause of Death. .. . . . .. .... 410, fi- z,-
,
Certificate was signe by ..1'2 ,/ M.D.
Address �'i � 1 7.
Place of Burial (or Removal) ��'+lfl-t0'z'/
(If body is to be to orarily held, fill in space later) /J� - /'�J 1(� 6Cemetery 1-ti"-<-.)//t.c'"`. v Date of Burial t�/ _ !!
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been prese ted 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/th/e asis thereofH EB GR T A PERMIT
to 7/ - 7de4*`-7 k_ 4i '
Qdlres�s
CyC 9
(Namthe to hold temporarily and the body.
(Under 'er or person having charge of corg�sse) to emove, or ise dispose of [state howl)
+►
Dated , 2-* 192.So. (Signed) Local Registrar
This '�' ,.it 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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