Hewitt, Anna NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr Thie Permit can be signed only by the Local Registrar (Deputy or Subreginrar) 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.J%.Q ..-....
� _�ie
County--- » QA.� a//i Town J.Village__ ..,.
ity
(If city. Ewe urn< sans)
Name of ceased_.___-. �"� {I..--- •. .Y_._ ilL G .
//,/�� . o�d
Single, married, widowed, '
Sex_! __...Color_ _ t -or divorced (write the word)._..i�ZG4 _ C )ate of ath.. Q ___,19.. .7
Age__ ..Year' ._.__.._; ...._„\lonths_._._ ...__._..Days Birthplace.... _.
Cause of Death._. __ . .._. .__. ..
Certificate was signed by__....._._.... . _M.D
Address._._._._..._._...__....._.__._._._.. �._... ... _...__...
Place of Burial (q{8emoval)..__ ..&t4'Z d..._ ....
W!✓Nf __..__.._
11f beds is to be rem heW, fill to work( ,
Cemetery____._ _. d C4..,_,_(L�{�. .. Date of B rial._...._- _2 _19.�7
(If body u to be temporsnly held, fill in spec* later)
The Certificate of Death containing the above stated particulars, having been presented to me, aftert'9reful examina-
tion, the same appearing to be COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW,
I have ac pted the same for registration, a recorded it in my Local Record with the above sated Registered Number,
and on basis thereof I ERE G A�3Z',/P,yE-R-bIII
the _ __.._._. ..__..........._._._._._.. . .. ....__._. ._._._....__..to hold tempora ' end..._.. .._ ...._. _. th y.
(Und n k w of< Or le (s
) r, ore ale lone I)
Dated___' .._. _ ft .... ' 19.. (Signed),__.. ._. ._.
al Racism:
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to part the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS o. 62) is required.
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