Jenkins, Samuel Form VS. 6t.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
w-Thi. 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, LEhGI Y(WAITTEN IN DURABLE BLACK INK.
Dist. No...0 1st/ L _... Regis d No_............... . .
Town
Count ..._.. `- .,.., .. . .._._.............._..._._._...
or-Ci tU city. give street address)
Name of deceased_.- _..._ .. .._. _ . .. _.__._._..__...._._.....__...._.._._._
Q f'ngle, married, widowed, - ' � // a
Se - ry-Color r divorced (wrirt�e the word)_ ..2.4.4-.q!..Uat L Deatl if.__.__..19.
Age__._ h Years___._ NIonths___OL2._ I)a ' Rirth slat
Cause of Death_-_--. ._._...._._............ . ... ..
Certificate was signed by..__..__._ �....._ ...._._...._._.. _yy�.St _.._.______..._..� �___._M.D
Address.__. __....._._._._._._�_..._._._._...._...... _ _. . . . 2.�. _ _ .:._.._.._ _..'......_.._.__....__.__..__ �.
rePlace of Burial (or Re vial)_.__.__.._...._._...._.,...._._....... . r _ ___....-_.
(If body is to be tempotor h< Il in pug bt
Cemetery____._.....__._._ .--Date of Burial _._ ._. ._. __._..�_.__.�._._. a1 1 19. _C
(If body is to be temporarily h . II in space later)
The Certificate of containing the above stated particu rs. having been presented to me. after careful examina-
tion, the same al) ring 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 the is th� J ereof �I HEREBY A PERMIT
the_ __._ f/{areet ccl!'+ _.____._.__._ _.to hold temporarily nd.__._..._-. ,.fa./,. the body.
(U t Ice n yyavara charge of c�j y mar. avyve. or ochennior''arse
of Istate bow))
Dated .1._ i 19....1..I. (Signed)._.._.... _ �` G�ese
. .. __._. 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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