Barney, Adolphus NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
alir 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 I I hN IN DURABLE BLACK INK.
Dist. No S.7 ,.G...ta Registered No
County l.,t.5 .... .... . YLA 'Village rC.0.,YL i,...ea/LaCitit...9-mww•(If city, give street ad
Name of deceased ,t=fyLarj,
Cid'treSingle, i arried, wido d,
r divorced (write the word Date ath.. /V 19.3..7
Sex�olor� )
Age 6Ali Years sir Months t.6 — Days Birthplac' .., fir,?/
Cause of Death . .. ... . .
__Certificate was signed by . ,. /L.l....,r... YYL' bLD
Address /V, ^e (�
Place of Burial (or Removal) .... tA I,/1.T71� p .. . W C1LQ-e.Y..t.� (�-.C.a• ,
(If body is to be tempo�ly eld, fis s '' t ter)
Cemetery ! iff ... a... .. . Date of Burial J.Q.Q..e_..e..s. /7 1%_97
(If body is to be temporarily held. fill in spa• 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 has' er I HE BJ` T A PERMIT iSketict4411_,) la+i/,/�,,
(Na ) ( ess
the to hold temporaril ' and the body.
Undert ken or person hating charge of r se) (Inter, remove, or o ,se s se of [sate howl)
Dated •r /�R 19 (Signed) c
I,oca! Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to an part of the State (subj t to local cemetery
or other reguiations), unless removal is by common carrier, in which case a Transit Perini (VS No. 62) is required.
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