Jarvis, Adele Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
82r 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, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
Tun ,Q� �7
Dist. No �2 County. Village, ' ✓_�� GZv ! ! '
or--G{y— , (If city,gives address)
Name of deceased.,tz51.4.,.. .. . . .n.
Single, married, widowe T.r,, ,,c
Sex /-- Color ' r divorced (write he word Date of D lW
Age 7n Yea P Mop�hs.... Days Birthplaces-�� ' Lf
Cause of Death (r
• '�A
Certificate was signed by ! - M.D.
Address `..... ---
Place of Burial (or Removal) - Le-c
(If body is to be tern ly held,ffi1 In_grace lat9rrr G
Cemetery !: `4-� �/ «' "�- Date of Burial../.....// — 19 3¢
(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 he 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
Num , and on has' the ,I HEREBY GRANT A PERMIT,,
to - limo ' V-ig-en-ea' /7'
(Name) (Address)
the to hold tempor rily and .f� the body.
( - ertak erson havingarge se) _/ Inter,remove,o rwise di ose [eta howl)
Dated... /. r./G�—19.. (Signed). CC .
ocal Registrar
This Permit is suff•-ient for the Removal (and Interment or Cremation) a bod to any part of the State (subject to local
cemetery or other refit,. :ions), unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
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