Bennett, Katherine Form VS. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
llillir 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 LY "BITTEN IN DURABLE BLACK INK.
Dist. No...a)6 !/....7 Registered No.
Town
County 1/4. .CA,A./`s ,,.,r, Villagc �4lS-C
OT Clty (If city, give street address)
Name of deceased _ .
• —' married, rv�e�s�td,
Sex.. olor _ or ci). •.. .... . ... Date of Death .2_!�f.:.19.... .....
Age .... .. ..Ye Months /� Days Birthplace..ckS
..
Cause of Death 0. .
Certificate was signed by _.. . .... .. / . ._ M.D
Address 4 ... .... .. . . ... .. ... .. ...� .: .,1�._•....
Place of B rial (or Re o al) ...._... ... . . .. r ...._... _... _...
(If body is to a raril he , 1 in space latter
Cemetery... Date of Burial 9.--iA.L1 � 719 3Sr
(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 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 the basis thereof HERE 'GRANT A PERMIT
to . get-4,4 , -Lf-,e1.. X.yf.
ame)
the. ... +e-4j134.4.4""e..' to hold tempor rily and L'X the body.
ndgrtake lhatgo-of cosily) er, remove, otherwise of [sate how])
Dated 19.0.e (Signed)...... se
Local Registrar
Th Permit is ufficient for the Removal (and Interment or Cremati ) 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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