Housman, Sarah NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lt'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.. -s Of Registered No.
�j� "Town .
County_ /IQiYLYLI.r+.-._.........._._..........._.............._........._._._...._.........._. Village . ._... .), / `t�_/L_.
/ or City (If an% girt sett .dares.)
..._ '
Name of deceased ..e C 7f. _ tiratn t - .._._.... — - — ........_....__..._..Single, married, widowed, y
Sex .'j-olor _.or divorced (write the word). . .._.__.__Date of eatthh...._. .._.�...-l9._S�
•
Age__. !¢--Y ass._._._..3..........._Alonths .....0 Days BM hplacc ��"�� 1-► •e0.� _
Cause of Dea 3��.j <
Certificate was sign by ... _.-._.-._._ __ y� M.D.
Address_ �.,�j`�L /7� .-i
Place of Buri I or Removal _._......_. ...._._.. ._.�..f III.•4,_. �._.__._._ �.
Ili boar is to be mponnl the at spscr tat �
y
Cemetery_ . . . Date of Burial....._._ __ _.19 3
Ilf body is to temporarily held. fill in spare later) -'---�'_._...__._.__._.—_._
The Certi cate of Death containing the a ve stated particulars, having been presented to me, after careful examina-
tion, the saint, 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 t basis thhejreeof/I �sfEREB G ANT A PERMIT a
(Adds...)
the___..._....__.......... 1 .._....__._._...._._._..lo hold temporaril • ....the body.
(Una ker or seer n hyg charge of ) ter, e, or otherwis of lame bow))
Dabd_._._._..... 19 ... .. (Sired)._ .... _............._._..._.........._._._..
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 rrmoraf is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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