Akins, Burton Pas VS. 61.
\—.11,
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 thy) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE Oi-
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No....S..G2.7.._.... Registered No..___.__.... . . ...
Town
County___Zaa___..
or-Eity (If acr. give street ddreul
Name of deceased. )_..(26.c.a.a.e - -._...._.._._.... _ .........__._._.... - - -
• Ingle, married, widowed, • .
Sex7nab Color divorced (write the word). _ __Date off Death .... .4.._19. ./
Age G 3 Years_ _ ?_ Months_._-1J __Days a Birthplace._C .y.
Cause of Death_._... _ _ C t0 tt4rele I ,E_ : �g., a2r
Certificate was signed by_.
_. p� D1.[�CE
Address.— .-.. f -atr — ...ca i'i.-._.... .. • �,. _ .•. . -._-
Place of Burial (or Removal �a/�, i" l%.n
(If bodyis to be temporarily Removal)........_ _________ ._. L( —,-,—
Pasrilr held. 6R in apace luo).__,`� �[�� `7� ��
Cemetery___.____ _-.-__-..6l!a44.1<ter.�^AGl�.Date of Burial__ -P- _ /.r 19+3(5..
(If body is to be temporarily held. fa in space 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 sated Registered Number,
and. the basis/therenoof I EBY GRANT A PERMIT �/ �
to._.._.. .. a l.._.....1�._ ._._._......._...._.._.............___ ._._._._..o2 s2.1..._�:C1� .__. 5��._�=�Kwtio 1i
t ._ . . ._. __._...._.........._.....to hold temporari • and........._.... _ ) _.the body.
IUnyrykn m wn haying charge of corny) •
.2 te otherwise d ..__......_._./a'a9/ G4i,.a •vv�� (0 doping of luau her))
Dated._.... Sa S L_....__..____19a. 77• (Signed)..._.. -._..._...._ .•
Local 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. —
s
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