Van Deusen, George NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Is-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 CERTI•FICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. ..3.11.2.... Registered No. /`4..`-
�}y
County._.._. " ^ -_ ,�'^ TownVillage. fit �n---,. ._._.—
/� d
Or Clty (If coy, give/street address)
Name of deceased ._ V • �4n� ,..i
,, n,, Single, married, widowed, J
Sex..[' -0-' - Color.f"rL or divorced (write the word) ..._ Date Death t.(s,.rh..a 19. 17
Age - ,� Years 13 Months 7 Days Birthplace t. ,tP..._...hy
Cause of Death .. . .......... ... ... . .... ....4( .
- C-ertifteate-vas signed by- ---- 4 11_!1......... ... M.D.
Address 977
f _ ._...._............._...._...._........._
Place of Burial (or Removal) w )“-C •n.[iaar2 :(If body is to be temporarily held, fill in space later)
Cemetery Date of Burial ,/ v 193'....
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been pres tee/ 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 basis thereof I �H E G T A PERMIT
(Nave) '' (Address)
t17) °- a./2 f2- 40 (1..m.
t e . . ......_.. ',f----� '�%�' to hold temporarily an >.....1 a1 the body.
(Ulcer or person having charge of corpse) (Inter, remove. or otherwise dispose of [state how))
Dated 4_.. v�...a... S 19.3_7.. (Signed) `"/ e. •042
egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pa 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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