Austin, Georgeania NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr 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 4WRITTEN IN DURABLE BLACK INK.
Dist. No. " • Registered hjo.
.�; ,Few-, f ' �, f"-'
County... .°s l �'illage�,r'�r. .....L:., .1� �',� `� -t—�f c
2 / .C4 t y, - street a /
Name of deceased 12e2 61Ki• —
��—' j/. Single, married, idowed, t^ �.
Sex d `Color l...l....i.•....•..•or divorced (write��the—word). ..,Ctf .. fir/ Date f Death.... ... -L?..t...00 19.07
Age Years. Months 7�l At ce
Cause o Death
Certificate was signed by M.D.
Address
Place of BylA (or Remov 1) t ..: .... ... .... ... ��,' • f' _
(If body is to a pbrarily held m Qace later) •� 1�1e'
7
Cemetery /. ,r.. ..�:..� Date of Burlal... .. .../jL/�'e'�� f 19
(If body 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 a pted the same for regis ation__have recorded it in my Local Record with the above stated Registered Number,
and on basis thereof HE Y T A PERMIT to /''.•J/
.(Yee, ii
/ 71
(Na e) (Address)
.the.... to hold tempo ril the body.
(Up a ker or pets 'havin to g4i-of cor 'e, (Inter, rettt�ve, o o rwise dispos of tate h w�l)
�. 'tl� j�
Dated.... ... .. Zr 19. I (Signed). ........ .. . . hLC'.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to a part of the State (su ct to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permi (VS No. 62) is required.
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