Palmer, Scott Form VS. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W.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, LEG BL WW rrEN IN DURABLE BLACK INK.
Dist. No. �1 Registered No.
Town
County.(-- . . . .. Village.... . . ........... ._....»..._.».».........
or City (If city. give street address)
Name of deceas _.. ....-
�y�,� le married widowed
Self.l2I Color4W: .. divorced (write the word)`; .���6t4.to of eati(2GZ.eAs 19..05- —
Age GP...7 Years... ..Q :Months err•-'.__.. ..Days Bi place. ‹,� e--//,(
Cause of Death •...» » ............. .... .. �/
Certificate was signed b ... ...- — fF.,_ _... . .... tom M.D
Address... ,�... �.�,�1 ,/ C�.
Place of Burial (or Removal) ... Jnl�iir e,. _.s
(If body is to empora'ly held, in space lat /�_t/� ��A� le'-
Cemetery
e � .�$#r�t� FrieF6Q 1✓�'20- Date of Burls ... .. ��- 19.•3
(If body is to be tempo rily held. 611 in space lat
The Certificate of Death containin -thhe above stated particulars, having been presented to me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on the basis ,�thereof�IHHEREBY GRANT A PERMIT
(Name) t� Addrasa)
thei 2eie.FI��� �prs�i ,�P 4e s .t 4-6 "to hold temporarily and. _ the body.
( rusiker or person havin charge of corpse) Inter, re ve, or chemise dispose of [state how])
Dated .... .A. , ._....».....1$.11i:^ (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.
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