Woods, Marjorie Form VS.et. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q This Permit can be signed only by the Local Registrar (Deputy or subregistrer) of the Primary Registration District (Town.
or ) in which the death occurred after the FILING and acceptance of it CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
ToDist. No.'s 4 O Cog7)4,41144-- Village�
//,J or itJy/�, .•• •• •(II .lire at address)
Name of deceased.yl )lL,l..il4rx/.C!✓..!
Single, married, widowed, _
Sex Color... or divorced (write the word) Da Dea ,.i 193.:
Age ,/..�4� Y s. le Months Days Birthp .�. .'/
Cause of DeaBr
Certificate was sign y.. . M.D.
Address.
Place of Bu ' or Removal
(If body La rarity Cold, )
Cemete Date of Buri .2F Ist
(If body Is to temporarily bell.fill In space later)
The Certificate of Death containing the above stated particulars, having been presen ed to me, after careful exami-
nation, the same appe ring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I • accepted the a for • tion, have recorded it in my Local Record with the above stated Registered
N on the is EREBY GRANT A PEGR�l�' 2�
.. . . - ..4(caza.r .. .. . . . ... . . ..
4.
(Name) (Sadness)
e to hold tempora 'y and the body.
or pe a having e �.o�) (Inter,remove, retie die of(state bow])
Dat . . ;X.,. 19. .X. (Sign �grJy�,'
This Permit is sumGent for the Removal (and Interment or Cremation) of a body to any p of the State (subject to
cemetery or other IlleL. .dons),unlsse remove/is by common carrier, in which can a Transit Permit (VS No. 62) is rennin
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