Burnham, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Pir 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. Registered No.
,..aliast.-,,,..-,• Town .
County Arimr---& Village.
. _...).„,,,i__,-- / • or&y (If city, give meet address)
Name of deceased
14./ or divorced (write the word) Date of Death,Single, married, widowed, - -L.- •3, -5 ..., _
Sex -Y1ColDeath, , 19r 7- /_
Age 7--v-- Years 0 Months f Days irt place 4'c) '''---. -1 ‘----0 C....)/PLY-V-4, kt..,
--,
Cause of Death .. - /
4
Certificate was signed by )7L7r7.7 ,/51.,A---i-cr M.D.
Address c--,"
Place of Burial (or Removal) - -
(If body is to be temporarily held, fill in spac la LI)
Cemetery Y.-412 /-C.--C..A-4-1.— Date of Burial.. - - V(c 19 2
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to m , after careful examin -
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded i in my Local Record with the above stated Registered Number,
and on theAasis thereof I HEREBY GRANT A PER
toh
6'6 1hc6
1 ..„ - SC 4.-.4
(Name) (A (A s) •,/
the . / t Id temporari a ...-/the body.
,
Dated
(tKier ice or person havin c arge 19. 2 of corpse)__
' (Signed)
Local Registrar Thist.,..1- po0/4.
Permit is sufficient for the Removal (and Interment or Crematio of a body to any part of the State (su ject 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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