Micks, Mildred Form VS. 6l.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
E'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 CERTIFICA OF
DEATH, LEG�IBjJ4 Y�{{��RITTEN IN DURABLE BLACK INK. v�.
Dist. No 7..v 's/ _. Q Register No........... _........_._._._.
Count ARATQG.A ll"e Saratocr,a Springs, (1f
_ or City of thy. give ureet address)
Name of deceased... .. . -------'
e i Single, marrie , widowed,
Sex__L_—__Color._..( _.__,_/_or divorced (write the word).__ s Date of Death.._ _ .__. 2 _19.4.
Age.._.Z.. "._._._...Years_....-..7.... .Months_._._L2. .. Day Birthplace.._. .
Cause of Death..__._._........_.._..
Certificate was signed by. ,2 t .. __a -r t M.D
Address.— ,,......7/'.. ! v._._.._.........._._._._._._._...._............_..
ee y
Place of Burial (or Removal) .. ._A Arae�..._ -- - -
(If body is to be tery�y-�y held. fill in space tat r) __ A
Cemetery_._... G�f _._ .. _Date of Burial_.__._._ _19..t,1.
(If body is to be trmporady held, Ill in space later)
The Certificate of Death containing the above stated p culars, having been presented to in after careful examina-
Oun, the same appearing to be COMPLETE. COR .CT. 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 the bits' t ereof I HER Y GRANT
to.. ... 1. , -�'�! L.�iK-�—.._ rid&._ 7. /
(N s) Addrr)
the... ... ..._. _.._....... to hold temporarily and..__. _._.__._. __.____.-__ -..__ _.__... the,bbd
(Unde ker or person having charge of corpse) (Inter, remove, or 'i �amm bowl) .s y
Dated..__..__. _.,"...._.2.2° .G...__._._...19.d� ,` r
!i
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any p echo • (subject to I r
or other regulations), unless removal is by common carrier, in which case a Transit Permit l o. 62) is
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