Brown, Jennie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
imr-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 WRIZTEN IN DURABLE BLACK INK.
Dist. No. 174 2, Registered No..
Town
County C4- Village �� �Cz-� •
or C. y (If city, give street address)
Name of deceased 2Ze.
// ����� i le, married, widowed,
,�iP Years e,[-�r divorced (write the word) Date of eath.... //e4....eff4....(c-A-Ce--/
1
Sex Color..
Age Month ff' Days Birthplace....
Cause of Death
Certificate was signed by M.D
Address ,9 '/ a"
Place of Burial (or Removal) �%- -t-t�.e U--L �
(If body is to be temporarily he , fi ,n space later)�/
Cemetery �`` r Date of Burial -S 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 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 there HER Y G T A PERMIT 414 C:e, '
to
(Name) /- (Address)
the " f to hold temporarily d /� �� the body.
Dated(Und- ker or person having charge of cor s (Int , or rthegrite. gGCc( (state )
�� `/ZL 19.. (Signed) L// 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 loco 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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