La Pier, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or Subregiarar) 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, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No... //
S O R ' erred No....��._L ....
Town
County__. ._. ___—.__._...._. Village.. /7
or ity (If 1v. give .vest address)
•
•
Name of deceased___.. E. aC Q._.. � .k.t..J_._._.___._
/.� �r,V`—ingle, married, widowed, •
Sex.____._i Color..._._Y— r divorced (write the word ...Date of Death___/__ �2._19..L 7
Age.._._.Jt_1_...Yea ........._... ......_..Months o'l.._i Days irth place..._-� ?.CCars.,G--
Cause
of Death__ _ _ _—
•
Certificate was sign by ... • �__._._ �... ._._..___._..__... M.D •
Address.._ .,e7x-�^! �
Place of Burial (or Removal) __ :t 4 ...._... __ ._._... _ . _.__. __.._.. _...— -----
(If body v to be to po tly h in .D later)
Cemetery __....._:_... Date of Burial__D1..ZS_._____193 7r
(If body is to be temDoranly held. /I in.pun Wise)
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 di basis there HEREBY GRANT A PERMIT
Name) Addrrra)
the_t ......._._. . _...._...._._._ .._._.... ....to hold temporarily am ..._.._. __the body.
(Lind ter« _._
��_ perpon ya ''g�g chore of coy im remove or otherwise dispose of late bow))
Dated er (-a'"'+� / O- 19. (Signed)._. ........_._. _._._.. _______
).oral 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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