Bissell, Julia 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�r ter"
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. 1f iR..0 / Registe ed No ( 3€;5—
��--yy Town
County 'v7C(.. 2 .-G-te i Village /3
` . City (If city, give street address)
Name of deceased ...
� �� Qngl married, widowed,
Sex - pI. Colorf!/i/`LL .r di rced (write the word) Date of ath -�l9'• ..� 19-.-, 7
Age 0 Years Months ./ Days 'irthplace 04--/Zzi. -71
Cause of Deathe'(Certificate was signed by - • .. . .. ... . . M.D.
Address • ..
Place of Burial (or Rem i) -71
(If body is to be temporarily hel , in space later).� 0--
Cemetery . .,Q, . . . Date of urial .. ... / 19... ..7
.-C
(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, fter 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 RecordJ with the above stated Registered Number,
and on e basis thereof I HE$,EBYR`¢ANT A)ERMIT ,�-tCO C�/GC at
Address)
the to hold temporal' , and the body.
(U er or person +'v�g cXarge of corpse) Inter, r otherwt ispose of tsta how))
Dated ✓ �� 19..3 7 (Signed)
Loal Registrar
This Permit sufficient for the Removal (and Interment,or Cremation) of a y any par of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit (V No. 62) is required.
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