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Carpenter, Roger NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT W 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.S O f Registered No /�7� 4, Town / / �r.f County l� Village.4P �'"'i Z�' � / ' Q,Q Or City (If city, give street address) Name of deceased..i-1 r ��?"2... ....!L.rG` y -fit / / ./ Single, married, widowed, _o Sex +Color lzi-Aa or divorced (write the word) �`� Date o Death I; 1977 Age Year Months. // Days Birthplace �j..A ) �. - Cause of Death :, .i? c -z of ••••. '� Certificate was signed by 041-• // /� �� ...� ... ••. M.D. Address ,� 7 4 -,. /,� • ' Place of Burial (or emoval) �. !� ''4- � �.t �Q " � (If body is to bet ora ' eld ll in space lot Cemetery Date•-of Burial S A 19 22. (If body is to be temporarily held, fill in space later) The Certificate of Death containing the above sated 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, taond on he basis t reo I HERE GRANT A PERMIT �� �tj��4 7, nA i ame) (Address) the to hold tempor the body. (Un taker or pe son h g charge of c remove, or of i dispose of [state how)) Dated 19 J" (Signed) ... .... .._ Local Registrar This Permit 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. r. x'C/17.. 0 CO a.)-0 , ^w ,__T. E O u m 4' C.'C..w y ..�.._.0 O ,,... O ~ �'" a.S•,, N O "y C ai p° V O+ - O�'tt .0 v 0iC O tti•... 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