Van Auitucerf, Rebecca Form vs 61. 6-8-34-50,000 (17-7901)
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(,,,LLl lf� Re istered No.
Town
Count` .a heir Village
���pp or Cit - (If city,give street address)
Nam of deceased....�l 6-14 e- 743t- r
S6 y�� � / dr divorced
reedmarried,(write
theed, / 19 Z '
Color . . / r divorced wr/ite the wor 3 p Date of Dpa
Age...ire Years LO Months.../7 Days Birth lac
Cause of Death j. / r ¢-'
Certificate was si y V ., , M.D.
Ad-dress ...... . . ., ..at..erlyt CriZ
Place of Bur'al (or Removal)....X Zrek --4 /e ,�')'/
(If body is to b- porarily lr- i,fill in space later) `-
Cemetery... 4# ; - Me a�-e of Burial... C- - .. 193f
(If body is to be temporarily fill in space later)
The Certificate of t ath containing the above stated particulars, having been presented o 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 HE E Y GRANT PERMIT --
�YAK,
the...2l.. to hold temporarily and the body.
(Undertaker or pe aving&barge of corpse) er or rwise dispose of[state how])
Dated.. . -/AC 19.,30f.. (Signed)......... ..
Local Registrar
This P mit 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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