Taylor, Ammis NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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 YWRI ' IN DURABLE BLACK INK.
Dist. No 9.5 �.4 Registered No
I o�ti lI
County,.... Village ����//
. or City (If city, we street address)
Name of deceased -•••-•-•••
Single, married, widowed, Zg 632
Sex 6 Color or divorced (write the word) Date of Dth 19
Age 7 Q Years 1 onths.. Dais I,. thplace ,10
Cause of Death �:/.... __....
•
Certificate was signed by _...._....._.M.D.
Address
Place of Burial (or Removal) �.
(If body is to be temporarily held, fill in space later)
Cemetery �� ate of Burial /� �(I 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 my Local Record with the abo a stated Registered Number,
and on the basi ereofHEREBY G T A PERMIT
410 to •
(Name) /Y (Address)
the to hold temporarily and ✓ the body.
(Undertaker or person having charge of corpse (Inter, remove, o oth of Est.
Dated Ykle47 �0 -•f 19..3 (Signed) t i..._ _...._..... t
Local Registrar
This 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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