Hersey, George NEW YORK STATE DEPARTMENT OF HEALTH .
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Ton.
Village. or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
t.LATH, LEGI Ye IN DURABLE BLACK INK.
D n. No.. ., ..L.le....]�... Regis g No..
Town fl
County---- _._._._. T ag - -
W.::
� }.orCi (If atf. tin
tv.. adds..)
Name of deceased. __w..a_.... _ ._._...._. _. _.
Ingle, nlarr'4 , widowed, ',/ •/ � �•,/ _Se Color . _ r divorce vrite the word)fSh..€4 . .... Date of Death_ _ 19J..7
4ge.._.._. �. Years___i....__._. ....1 mths _ _Q_._..Days� Birthplace... Lti e?
Cause of Death_.___.__._____.. .. -' __'t-�'tni - --
Certificate was signed by_._...- ___.__ . .-._� :x._._ _.
Address. .__ -. __. __ ___-___ .----• _ _ -..
Place of Burial (or Removal)___.._. _.Q1Ft+'!L _.-
(If body is to be one 'ly held. rr space )
Cemetery ale-..._.Date of Burial. - 6 1937
(If body isto be re y held. ill in Woe tarn)
The Certificate o Death containing the above tated particulars, having been pres ted to me, after careful examina-
tion, the same appearing to be COMPLETE. CORRECT. AM) SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same for registration, have recorded it in my Local Record with the above seated Registered Number,
and to basis roof I ERpRY GRANT A PERMIT
�.) ( )
the L�� a ,e!_.- __ ._to hold temporarily and.— _ the body.
({edir da.wskn ee _Lilt charge et ) (Inter,cde . of roue bowl)
Dated_ ,t.i- __19 (Signed ty -.
Rylwv
Thu Perni, is sufficient for the Removal (and Interment or Creme • n) of a body to any pan of the State (subject to heal eemassty
or other regulations), rains removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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