Codner, Lucinda Form VS. 61. tifigt
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
glir 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, LEG,(IBLy W II1'EN IN DURABLE BLACK INK. 7 l
Dist. No....�,.,1�...®./�/... Regied No.
Town
County .y ti'illag ee ` C....... .....
or City /f(If city, give street addresss)) /"--"'
Name of deceased �C'<- ItG ... . .{ C,.,.,.,,W j C/
4 -� - Single, married, widowed, 7 y�i,
Sexy olor�2� .-Or divorced (writ the word)....1W. Date of Death.../ .... f:..,,. 1
Age ',-C Years ,:, Months .. Dam_ Bi thplace...r 1 . '
Cause of Death l j f
Certificate was signed by 0..,!----7-14r� --- M.D
Address -f ��...._. l- ..(.;
Place of Burial (or Removal) �t�Y�--Q ( ��z 4f/" k'.. . _ �111 .,.. ....,7
(If body is to be temporarily held, fill in space later) -. 3 ".
Cemetery t ( Date of Burial ' L..( 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 accepted the same for regisftation, have recorded it in my Local Record with the above stated Registered Number,
�� /�� .,an o, t basis they GRM A PE T HERE :liQ—. ��
tht----- �: ... L... .. 4. / to hold temporarily and .. the b y.
(U r ker orperson havin charge of corRsejn (Int ' m ve or otherwise dispose of [state how])
+p A B B
Dated.... . 19 ... (Signed) '{
r; .y ( g )
Local Registrar
This Permit is sufficient for the Removal (and Interment,or Cremation) of a boc 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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