Crawford, Mary NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
eir-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.5 7 a / Registered No.
County .� • Vim llage. � -4'4'6 t,
(If city, give/street address)
Name f deceased 2)(--11/1-1 7,-- Z.- ---ei.-1C1
�¢ S+rrgle, married, wi wed,
Sex'' Color�Y" e #irffrc'2d (write the word) Date of heath �"e -3'7 195 7
Age Years 0 Months /D Days irthplace ' ' " . < • (-y
Cause of Death C?,- '-u ...�a
Certificate was signed by !�'T�P-I/0 M.D.
Address
Place of Burial (or Removal) f ...... •s--- -ea
(If body is to be temp rily eld, ll in space later)
Cemetery Date of Burial '36 192.77..
(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 with the above stated Registered Number,
and on the basis there�I HEREBY GRANT A PERMIT
to C.Y.. )... (o Ge-.vc
ame) (Address)
the Tom- to hold temporariiyxnd ;�J�.j the body.
(Und it r person had g charge of corpse) -' a „Inter reel pose o ate how))
111(((//Ja��000JJJ d
Dated �- 19 3 (Signed) ✓ _rise— Z
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of ay to any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Tra sit Permit (VS No. 62) is required.
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