Hulpur, Samuel NEW YORK STATE DEPARTMENT OF HEALTH \
OFFICIAL BURIAL (OR REMOVAL) PERMIT
as-Thu Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (To-m.
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.
Din. No. t 8/...,....._.._. Registered No. ..............__.. .
Town
County ___._...._._...._._.._... Village.__._._......_._._..
or City (If city ire street address)
Naatneeool dde/ceased `-._ . . �•-�-
xt Single, married, widowed, � �l ���- �/j
Se Color or divorced (write the word)..` �tr�"r� a�S--..Date of t_ • 2 19_.
Age- -Years......_..,...._.._.__Months. __._Day Birthplace
_-- ause of cash _ ._ ... ... /_.._._.
Certificate was signed by....... ._._._._.M.D
Address._._ -.... . _
-- ,,fi�ee . ...._._..._.._._..........._._....._.._._._._._._.__......_...._..._...._..._.........__....__.__._....__...
Place of Burial (or Removal) ._ cS !t.__—_.___._...._.
(If body is to bet my held. filttin•spacr fiter)
Cemetery ra.rtager_.. // �_sa gt. __.Date of Burial. ._ _,_sr�_..—._.. _____.191iJ
(If body is to be temporarily held. all in later) ,
Tne Certificate of Death containing the above stated particulars, 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,
and on the basis thereof I HEREBY GRANT A PERMIT cI ,
(Name) (Ad )
the . . _......._...._...__..........._....._.. o hold I itporarily and __ _the body.
(U emkar or sytn having charge of c S (Inter. rtmo.e• or othery ,pose of [ u I)
Dated_._. pry
19. v
Oet.... i� ..� a ;•,grace _.._ (2GlS .
..• Local Registrar •-- c .
This rmit is sufficient for the Removal (and Interment,or Cremation) of a body to any pan of the State (subject to local cemetery
or other regulations), unless remora( is by common carrier, in which case a Transit Permit (VS No. 62) is required.
L.
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