Belden, Rolland NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
SW This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the P isy..;Registration District (Town,
Village, or City) in which the death occurred after the•FILING and acceptance of•a CORRECT ANGpMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK.
Dist. No.`r2 G -' . -�` Registered No.
�j Town
County'.....1!/ Vi Bege...,/�
Or City (If city. g. street address)
Name of deceased
/, Ingle, married, widowed,
SeRt.-.Color4 divorced (write the word) Date of Death 4-""---• 4 193f
Age Yeail Months i Days Bir )ace
Cause of Death -Q ,j-A- - I
Certificate was signed by t(, & e C-�-�`,� _ � 2f- - M.1)
Address
Place of Burial (or Removal)...body is ry. b t r por y I fi ir.space or-
(If /���( ��C� �� 19 Jr
Cemetery. ate of Burial
(If body is to be temporaril 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 on the basis thereof I HEREBY GRANT A PERMIT
to, �. , ae w.a
� �� (Name) f_,..,,i,_„, ,e.g..., ?ti,
(Address)
,
the ?6' ` to hold tempor it and Z the body.
(Un a person avin charge of co a (Inter.,me, dispose of [state howl)
Dated / z
yt I9 (Signed)_
Airt Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a ody 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.
ao c + o sy c »,cti _ cw t� 'o� n'o C`^ 4 -to M o = ..,-•� o'o cn-,
nT.ep 't r. O ti O O n O 0 SA O O c r, S n e: et .O•. .3.p .-1 '.y O•.7 ....(1, 1-V O•"C V) d
^• `-< _ " n IIII, "' 0 9-Q n<< R G.O.r- n �'O w a' .~.o ,- O r, - O H Cm. _ c•O m O °' Z n " A
n n, •n C c O O - r C et, 7 d O ep ray
,_ - _? .`', SR „ <, nw�g-< = - co ^:sc<,m .? N'5..o 5 E:s� g `' e'o, Co 'o d" m �.2: ig,... - -j, 7 _.rr o -w 3 _i3 `, = ---_ n c`- ' AT= v� = rr c-v _ _ _ r-- -, c et ^.5.Y 0 A a. ".. 0
w ('O p
c J ...FA ELF!.
w C e�p R `". C^ - - - = » _ .= J'_- - r - ^ _ ' _ ,- = g p--'°bV g m i V[f1
�OQ C� ep ep g .- _ .-v - 5 ! 1•.. _ - N 1-1 n -1-i t R r4
�cy Z n a ~ ^ • c_i •
wt ay =r r g F
�c3m°'T .nZa ' = O _ * -_,Ft = - *_ ^ -� _ _ = _ - „ m r R r>m0 v _ y £ Rin S3 - *^ . » = - • he-,
•
_� c _. _ - - --- - �g o 3< _ CAn++
1 ' - T - = - -.-i ' z -" r r - , 3'�y in' 4' W 0
• • r• -- - R7 A (SR nr "- -- - - _.=-OG. d •• (/)z .. ^ _ _ G f =- - - - ' T! ri
m SP' n n _ ,� - - -
Z.,'.i . • _- - r+9 - S•p tog - - n n - y n .- Y v_ __
z
. j< =- - » 2.. a6 .-. qAS ,'<a° : ., o " O % _2 ,Tp ' `" •'=� -_ C, ..e.c,.�R 0r
_ �n y gip `` � ---e, et - --r) <' � _-, - �_ H
ko
41
170 - �' o o •'•n:n w`.,, -� _ n - � _ -t ^ " ` Sv mOtt _..._ - _ y_- E �a.•
a2 ' _ - - ^-O co^S 7, -.-•c) y 7,F O.•-•*n -r� w 3 o O O 3 0 .-. O .y.� e = ?E �r tll
eo 70 R _' -r '� -, i3. n y - - c .n n C a." S ,,,'O'! S ,�"' ^- •_ F. -, O
r ...�S1 cc, •.' ^n S< ^•n .-, C' A [." .+.O S A: A R c !j RrA
-4s s, " , e n " w 0-, »-o = 0 ,3 r,' -n o'o vim, w .; 0 a+ •. c,) . o e w 3 c3 T °5.2CC `S
0� <-. `< 7.rp 3 ='O co.. O .. '+ O <OQ < A' - p+rt. .y O'.... O H O •, ..�"
n m.Oi. S�'•e n S." ? e?o-..y e " "• `e•vwiywc 4w a »,N ae''o° " M3'8 m A ti O 2 ...w ONp e<pe7 O Cx��
o. 3arh ».= aepo Ro ►1Z