Scales, Cora NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
"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 WRI.I i N IN DURABLE BLACK INK.
Dist. No. {/ .,./..4,..i. Registered No.
Town
County \ lllaC.....�' •
l2 (If city, give street address)
Name of deceased jel.r
( •
Single, married, widowed, -,/
Sex 1 Color r dig orced (��rite the`��ord) /i' Tate of ath.. C72 to�',/p
Age 1 21 Years '�l inth;, ,Z...lf )ays Iiirthlllace �
Cause of Death a.,"/
Certificate was signed by ,..: .. M.D.
Address ,�1 _ `J
Place of Burial (or Removal)
(If body is to be temis9rarily held, fill t space later) �f
Cemetery S1.- -5 1-W Date of Burial �-4'c' 4,0 19..!3.
(If body is to be temporarily held. fill in space later)
The 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 y Local Recor with the above statedte Registered Number,
and on the bass there HEREBY RANT P T C�' e_J-V I
to .. •
�/
a (Address)
the............................. to hold temporarily and the body.
(Under y4er or person havin charge of r (Inter, rem e, otp.t ' e dispose of a how
Dated a�G"- ' " 0.0 19. .... (Signed)-.... ✓ _..._...._......._ ..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subj 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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