Chadwick, Mary Form VS.81. 10-21-37-25,000(17-3459)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Kr 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 CERTIFI ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Re istered No.. - .._.._.
�� Town G j„.4. ,�i
Dist. No j G U� County Village 4
Name of deceased
�� or City (If city,give stree address)
',/ Single, married, widowed, 4_ _ /� �� �� /�� 193f
Sex "' Colk4 or divorced (write the word).. �'^—�� Date of eath I"#•
Age Ye s onths /-� Days Bir hplace...
Cause of Death.... . . �ai-s-..' 3 �'t^�—, Bi ,r-�„ _ �,(.?,H-4-
Certificate was signed by. .. ... .. 4 J�4' �s M.D.
Address �';�? t+-J. - )i. '�I " �'/-
Place of Burial (or Removal) %e`k- /..1 '
(If body is to be. mporar} held,fill in sp e later)
Cemetery ! — • Date of Burial 19
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing 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 ord with the above stated Registered
Numb , and on as' }e f I HEREBY GRANT A PERMIT /4
to i 4..r l t! °. ��"'�` � .�
Name) (Address)
the....... .. ... . to hold temporaril the body.
(Unde ker or p suing charge of.corpse) move,or o dispose of[state how])
Dated � 19. .d . (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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