Barber, Mary Form VS. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr 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 CERTI•FICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. /
Dist. No..H 'D/ Registered No. 7
Town
County Village. 3 ,7
Or City (If city, give meet address)
Name of deceased ��t��'�—� w...._..........----.......-.._._.._...........-......•
1 �111d Ingle, married, widowed, ,J
(write ) 7, 19..
Sex ColorG�� ,,;.or divorced the word Date o" Death��=�"�14.:.... .
Age Sex**",„
Yea A, nths f D,,��v.s Birthplace's � +a ..,... ..._...... .... . r
Cause of Death..._...... . .. � %►t�.0
Certificate was signed by , 1, 21/: 3; __.. _...._....._.M.D.
Address f ` - _ ....__.._............._.....
Place of Burial o Removal) • "' .... '
(If body is to be to my fill i space later)
Cemetery....._.. .... Date of Burial 19..d.t
(If body is to be temporarily he d, 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 of ie has' drireof HEREBY GRANT A PERMIT
to _... .. -7*,-L
Si..... 3
� .. (Address)
the .. .. to hold temporari the body.
(UV��e or person virg algae of cglp+ ....te ove, or o se of [state howl)
Dated 6 4 _ __••
..,r....19 (Signed).....
Local %Paccar
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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