Clute, Orville Form VS.sL 10-21-37-25,000(17-3459)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
vr 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, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. .............
Town Dist. No..11� ..0. ..County..../ � ^.1- L
Village �`�ft�`- 2 '
/ A /`or City (If city,give street address)
Nam of deceased..6 t�� - 'C.Y.. . .
Single, married, widowed, •
S .. . " . . Color.. or divorced (write the word) Date of De th. . 19. r
Age.... ..( Mo ths........��~..Days Birthplac !LlCaus of Death.,7),, -s
. >... . . .. ... .. . .�.� ieha .. ,61/.4T .. .... .. .
Certificate was signet by.. -&- .�����'^� M.D.
Address v/
Place of Burial (or Remov ... .
(If body is to be orarily h d,8 1 n e ce ater) v(/ C
Cemetery . .... . . !/illtk�l.:.. IZ-4 Date of Buri �� 19
(If body is to be temporarily heldc911 in space later)
The Certificate of Death kontaining the above stated particulars, having been presented to me, after careful exami-
nation, 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
Nu er -,t eJ� j thereP HEREBY GRANT A P�R1V (/�) � ��
�GTT �� ((��(--Name) (Address)
the • to hold temporarily and the body.
(u. to r or pe on h rin harge pee) / ' (Inter,r ,or otherwise dispose of[state how])
Dated... ..... y ..Aj 19.. (Signed) ,.: l,�a.� -14..- , .. .
L Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to y part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Trans' Permit (VS No. 62) is required.
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