Howe, Agnes NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir This Perth 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
ukATH, LEGIt13.Y W,1713N IN DURABLE BLACK INK.
Din. No.r ....��...../....... Registered No......_.._...._.._......._._...
Town
isount — _____.....__-_____._._-_Village- .---
or Cit III car. give greef•
~wavy/
Name' deceased earx�fa
�Si le, rodent , widowed,
S% olor_.4e ualT-/divorced (wri a the word Sft. ._Date of Death �29 -19
Age ._.7 Year ______ Mt it hs.__.___..___...Days Binhplac
Cause of Death__(t / _;_re. _ -�-ra e/
Certificate-was signed by_. 1.�. ..-__M.D
Address.111._ a-e��- _
Place of Burial (or Removal
of bade a to be tun ly held. 611 in stake r)
• Cemetery- + e��G.ratd_ Date of Burial_- . 7 1927
III body ,s to be ie peeenly held. 611 in late_..
Tne Certificate of Death containing the above stated panic ars, 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,
on the basis thereof I EB -GRANT A PERMIT ��
the - ,w• ,-_ _ . - ___._______to hold tempora • and_ .lit. SO a the body.
11 peesea having chugs oft ) otherwise divan at ( hew))
Ua)ed!' - . 1T .__._19 (Signed). Land Raw
�._.
is Permit is sufficient for the Removal (and Interment or Cremation) of • body to any part of the State (subject to local cemetery
or other regulations). mtims removal is by common caner, in which case a Transit Permit (VS No. 62) u required.
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