Miner, Philip NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
NW"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, LEGI L WTI N IN DURABLE BLACK INK.
Dist. No....79 /r R ' te N
Town -
i �.
County... . Villasc V�� ��y (If city, give street address)
N me of deceased
0 'ingle, i arried, widowed, .
Sex -e• Color. . r divorced (write the word) .... Date of Death. ............. 19 •57
Age f/ Years Months // Days Birthplace '1U 72 4, •
Cause of Death . .. .. . .. . ..
Certificate was signed by .44?(1,'- M.D.
r• Address 90c .�atl/• ' k a
.$ice/ �zR .... ...._.... ............._.....
Place of Burial (or Removal) . -S�, �. . _...
• (If body is to be temporar. e , fill in space lat )
Cemetery Date of Burial ... . / 19 ` 7
(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 on the b sis t reof I HEREBY GRANT A.PERMIT
. *me) Kddress)
the to hold temporarily andt€4. e.iL/2(
_ ...the body.
(Un ker or person having charge of corpse) _(( per, re9ve, or odterwise dispose of (state how])
Dated O 19, (Signed) `!'7
• Local Registrar
Th. 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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