Snyder, Lena torm Vb. 01. 0.10.3>•>U,UU(R(17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
glir 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 WRITTEN IN DURABLE BLACK INK.
Dist. No. J,1./...Z...... Registered No. .5 3
( �IiL?_-z'.7��c Town o /ez_-7,T t_f
County....._... _ _Village
/7 xOr City (If city. . e street address)
Name I deceased... --L—Gt
�" pp�� - 7,,,-�Single, married, widowed, 3!
Se `1""tolor `� Uor divorced (write the word) Date of Death..... ...�:: ..., lg .
Age �-� 7 Years Months ' Days Birthplace... .zz-_yW"{ ' —
X
Cause of Death 0--ti1---i,-`yc---'-=-- -��c-e_ ---,,_ r -�-i---z-`--<- -.e.--
Certificate was signed by LA ��•- --,9 `-, 60--7.-'C P1 M.D.
Address y —27 '
Place of Burial (or Removal) ,- GIB/.�
(If body is to be temporarily held, fill in space later)
Cemetery Date of Burial 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 he 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 E GRANT A PERMIT
(Name) ddz(
the ( • 1 • L to hold temporarily and the body.
(Undertaker or pesoaving charge of t
Dated �Q� (X l orpse) (Inter, remove, or otherwise dispose of (state howl)
�?
(Signed)_-'� ..a...rnP
cal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any p rt 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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