Dickinson, Irene 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 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 WRITTEN IN DURABLE BLACK INK.
Dist. No..(([ .. Registered No.
Twin 11 �, ` ' �
County ... .......... .._...dlC,...... Village.. ...w./�Ir/ :zl
or Ciry (If city, give street ad )
Name of deceased d."-t-cx_k_. ..,....�1., 't
Single, married, widowed, ‘ f
Sex Color. t...._.....or divorced (writf the ��ord) ............... Date of t c-�,,..�� ..199
/*---
Age �y Years C) \lonths v D vs Birth e _.../2-4C- ‘1 1/ ` ,
Cause of Death 4-'` ji
Certificate was signed by ?,--, _,.,._,,......M.D
Address 4)... . :..,.
Place of Burial .orlRemovall.-(..,C.---cl iZ /
(If body is to be to r3ri[y Meld, fill in sp ce later) — 1 L. 1
Cemetery 4.ft,t(,,_ Ia��" Date of Burial!/..... .. ... G4,,,,.2 19.(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented t 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 o the basis the of I H/E EBY GRANT A PERMIT — / ` )
to c.. r..4,....A..--1...._ ../W-6,Aft,-
11
(Name), (Ad ess)
th to hold tempor ril and e� the body.
( ndertaker or personJtav'ng charge of c ) r, remove, or oth se spore of [spte ])
Dated...: . 19..0,7.. (Signed) ..._r1�GRL[_ tr. .`1k:�1
Local Registrar
This Permit,' sufficient for the Removal (and Interment or Cremation) of a body t` 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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