Boss, Virginia Form VS.St. 10-21-37-25,000(17.3459)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CERT IFATE OF
DEATH, LEGIBLY WRITTEN INN DURABLE BLACK INK. �� Registered No..... ((rrJ�
1.
Dist. No County /4i! ^i. Village f: ;�..
or City ( f city,give street address)
Name of deceased r_ C,t Bo-'34
Single, married, widowed, n/I! .
Sex..;! Color... or divorced (write the word)...T/V,netkktntd Date of Death... i oorre- i' 19. '
Age ,4 Year ,,.3 Mo s....,..1 ' Days Birthplace...
Cause of Death P.:kn. .nll.�ai K.
a Certificate was signed by .sf. A.€4 M.D.
Address .c) ! .
Place of Burial (or Remov ) rt .z.4,lr1 K W..... P. y
(If body is to be temporarily held,fill in space later)
Cemetery Date of Burial.. .... .. .c....)•-...................19 r
(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 the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis-thereop I HEREBY GRANT A PERMIT
the °mZ) to hold tempor �r) (..cf.L ) Lbody.
(Undertaker or person charge oteorpse) r re therwise dispose of(state how])
Dated ' 419 3 ) (Signed).
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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