Stafford, Clarence 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, LECJIByY Vj TEN IN DURABLE BLACK,INK.
. 1 �,//�
Dist. No.. Registered No.
20Town
County 'Village. ...
r.. (If city, give street address
Name of deceased zy_terelionvcer--.
/� j'+^ v"T
Single, married, widowed, A.
Sex . .. j. Color Cat" or divorced (write�he word)�� 'I llat f Death ea.N......19 3
Age 6..4( Years ! 'Months (� Da vs Birth Iacel, Ti,....
Cause of Death
�?:IC ...E t
Certificate was signed by o �_ dam.- _... ,,( _...._........M.D
Address / 2/ t� C et,..SIT,j' (. t4.., eg--
Place of Burial (or Removal) .T ...c„ 2 e
(If body is to be temporarily held, fill in space later)
Cemetery t t f a Date of Burial C.4 19..
(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 my Local Record with the above stated Registered Number,
and the basis thereof I HVEBY G T A PERMIT _ce
to dam. :� .... ,.� QG���-�- �. �-'-,
fss)
the. . ,. ,[ � I ...Q... to hold temporarily and „,,F7 V_ the body.
(Uniertak or erson charge of rowel (hn , re ve, or otherwise dispose of [state how])
Dated..,,... . i[ 19.. ..7 (Signed) c7.1.r. ��Local„ .g
p Local Registrar
This Pe it is sufficient for the Removal (and Interment or Cremation �6f a body to any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case ((( Transit Permit (VS No. 62) is required.
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