Beauloe, Edward NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
air 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, LE945YgRTEN IN DURABLE BLACK INK.
Dist. No..N, . 1 Registered No
Town
County...( '2„„..°A..-- Village
or
de. 1,
o 19 4,, C' . (If city, give street address)
Name of deceased f
s -i/ -01ixt wii,e,o,rtcneadrr(ieN4d.r,i t‘Ne,itdhoew\evd,rat(p4e
0.....40.•26-.4r.leVDate f 402 a.
Age %,..? Years. 14%." \ltpths / Days hplace IZikfrillip
Cause of Death Cta.• All'a-"g"."-
...-
Lertificate• a 4,10 - 0‘.......0.9' M.D '----
Ad
drwe'sss.....Ape3 elOzo.. 7"Signe - . .0.09.
1.••••
Place of Burial (or Removal)
(If body is to be r ily held, fill i space later) ../0"
Cemetery 0 OF Date oft.:479. ., 19.0.. ...
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented t 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,
an n the basis there f I a REBY G T A P ,W4IT
I Fe"hegiff .
P.4(Address
the. ,71/1"ele to hold temporarily . •d the body.
( dertak r person having charge of cgg,par (Inter,I% • •, 11111:11. ise •' •se of [state bowl)
Dat .2. fr- • 19.y (Signed)
,000' '
Local Registrar
This Perm 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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