Flanders, Henrietta NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
illl♦`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
ilLATH, LEGIBLy WRITTEN IN DURABLE BLACK INK.
Dist. No. .*.. .L7 , .. �� Registered o.
Town
County a..r- . .,�. ...> .�
�Y� r�}t. (If city, diva street address)
\aine f deceased 4(-,......-..:i.i.L.-.11..t.i.--•tf...1/..{,. Single, married, widows , n �
Se ..... olor.W.„et or divorced (write the word).... ,Le-ed i .- Date of at ....K 4 2
Age F 7 Years Birthplace2" " yY•••...Months ,� Days
Cause of Death ° t r : 2.. ..� 'ate ,-- __••••
Certificate was signed by �J -•••• ••••• M.D.
Address �1 _- [_F .,. y�. .. v ..
Place of Burial (or Removal) --'Q--t---> 14r' ff. .:..jr. ............................
(If body is to be tempoyarily held, fill in space later)
Cemetery // 9e / t / Date of Buria - 14,reg-t-----.3 o 19..'3 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 me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT. AND SATI SFACTORY 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 the basis thereof I HE BY GRANT A PERMIT 4 1f/� • �1 `/
to. , " -I ., .. "-"-zd ti. �C �/ e % _..._
�'''') (Nasal) A,, (Address)
the -� to hold temporar• and... 2.:: - ` . the body.
Un km o rson having charge of corpse) er, a ise dispose of (state how])
Date -.4...V 19..[3..7 (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.
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