Chadwick, Charles Form Vs bl. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mir 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. x
Dist. No..... gi tered No.
Town
County.. ... . Village
Lit/tor City (If ci 've street addr s)
Name of d ceased _...
- Single,married,widowed,
Se Color/.1.:::. ... r divorced (write he wor ✓ Date o Death` 4-C 19...a 7
Age ° e / M ths... Days Birthplace. '
Cause of Death
Certificate was signed y / M.D.
Address , ...... ....�
Place of Burial (or Removal) l`u .. �`
(If body is to bet r held,fill'n ace I r) /
Cemetery .... • .... Date/of Burial L.. ........ . ...P..' 19.3 O
(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 accepted the same for registration, have recorded it in my Local Record wi the above stated Registered Number,
and s a basis thereof I HEY GR A PERMIT Pe
..
i
HEN
. . .
ame) Address)
the.... ... ..... to hold temporarily nd . . ..M � the body.
itUndert er or rs having charge c e) (In er,re ove,or o rwis is ge o (S a how])444.i.
Dated / 19\ % (Signed) L`/..._......1/... .... ...
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.
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