Lockhart, Lindsay rOem Va. OS.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
i(A'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 W/RITTEN IN DURABLE BLACK INK.
Dist Na __(.._.__.. �� /f Registered No...._../../.._
> "town ,�afi`/ '
County_ /!. ..... — _ ._._........ __ VeHagc_...._....._ ._.._._._..._._._.._.... ' — ' ' ._
y/rJJJ�—• -,- C jar'
M. give street addr<wl
Name of deceased_._.__...._st' .�_.—.�___...._ ._'.._. ..
l` ,�_� // ,, Single, married, widowed, •
S ..J�..k4�LG,._Color.4 ...----or divorced (write the word). D 'ofyeat j_ - =—_19.."
Age.. 3.-Years__._ _.._._._._._..Mopths_...._...._/...1__Days Birth /lac-t�* '� tie
Cause of Death_ ..SAlersn trot. . . ._..__ __._. ._ . _. _ -•s.QerYe• ._ _._._..__.___..
Certificate was signed by._._..._._..._._.._........_..__........_...._....._._......._...._.._._._.......__........../..�.._ R cd.f.ar_._ CARa e ' i. ..__M.D.
Address.—'---...... _ _. .- _.._...._. .-y (' mac.e-4249,-y r Cyr..___
Place of Burial or Removal).___. _. _ 3..._.__�y�.__ ._.._...._._/._.��_..•_._._____._. _q_..
(If body is ro br r r I yw. II in • later)later) Date of Burialy!__._._S._ :LsC_____.__I9_c
Cemetery ._�-.IP_'L.t�._.... _.........___— — --'--_..—_.—
(If body is to be tempo's/dy bald Ill an space lam)
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 • ereo I HEREBY GRANT A PERMIT
to .. ._. ._... .. ._.....____._ ........_._...._.__.___ ._._......... ..__._.__ _/..._. ..� _-._.._._...-
142,4 (Name) _ )
the. vl�t to hold tenlpora • (I_._. _. ._.._.._._ __._._ __the body.
Node soyhaving shirt, of,��i 1 (It nm• , lump of Istate
Dated-._ -_! ._.19. (Signed)._.. ._ ._......._.._._. . ___....._.....__._. _.._—_._
teal %turn
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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