Kenyon, Joan Form VS.61. 10-21-37-25,000(17-3459)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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 DURAB BLACK INK. Registered No.
9 Town
Dist. No.. / h County. .. - Village
or Cit (If city, give treat address)
Name of eased
Ingle, married, widowed, /
el'
Sex Color or divorced (write the word) Date of
Age Years.., nth .8..Days Birthplace "
Cause of Death ,:.. ,
Certificate was signed by.....�,l,_ .. .. ....,...... •
) M.D.
Address l// -'`?..,
/ /
Place of Burial (or R oval)
(If body is to be temporar e fill in space late 1 y p
Cemetery = �1� Date of Burial l/ 0 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 same for registration, ve recorded it in my Local Record with the above stated Registered
Number, a basis thereof I HER Y GRApiTT A PERMIT
the to hold temporarily nd the body.
(Undertaker oyperson hwring harge of corpse) ( nte move,o otherwise dispose of[state how])
Dated /,/ / 7.A... L.19 (Signed)... .. . , ze o of�J
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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