Liberty, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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, LEGIB Y ATTEN IN DURABLE BLACK INK.
Dist. No. (� al._... Registered No....._........_........,..._._...
Town / ''
County.____...._.._. Village. .. . __...._.__. _._...._
1 (if cit)q ai.. street address' _
t.
Name of deceased.____.-��, ✓ L1-1-''y..,..��4... a"L• /__
/y�� , married, a itlos'ed,
Se . olorlC ._._. write the +Nord).. _ • Date of Death c...�� 19. .E
h
Age.._.__.. .. _._. Years.._.__._. Months D •• i Birthplace„. .6s. _._..✓1j ..-__
Causeof lleath.._._._._...._...._._......._.. _._ .. _._. .....-._._._.._._..__._._._._._... .______._............. _ _ . ...
Certificate was signed by_........_.. �W.........L . . .. CF I M.D
Address._._-F-92w.n:� .. ---- vi _..C:Zcc: 0 4frici__ •
Place of Burial (or Removal) . _�___
(If body is to Inra temponly held, ter spars la ) /'` q
Cemetery_.__._._.._.__..___.. d—a- o .'.Ll .._....____.Date of Burial._.. ' •~. .G_y:__._.__I9s .y
(If body is to be temporarily hee • fill in spare 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 above stated Registered Number,
and on thehe basis thereof I RE/BYYSj GRRA�NT�A PERMIT�� � e
to—c-c--_.i:Y�,r_a •._.. s 'lrc-• N......_`n.:..�......Y._G_.Y �..�. • /�,2 4,. ..:��1Q_
the___._ .ti ._._......._._. ... ... .... .... :.__.to hold temporarily and__.__...._.. the body.
(U r w person hart care of co i ��gee;Tare. eFise dawns of loan howl)
Dated.i�1 r('' 1Q� 19..LZ :/ (Signed).Q �E� 7` .......1./_.._L—. /: /---._._._._........._._..___..
66 � Local R.airtrar
This Pe tt is sufficient for the Removal (and Interment or Crematio ) of a body to any pan 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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