Mullen, Francis NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
our 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.
Dist. No 1.7460 el/ Registered No.
^ •�I own
County (/J •
_ 1414age--
or CI }% (If city, give street address)
Name of deceased - .. .. t Wt
Single, married, widowed, �/
Sex...24 Color or divorced (write the word) �YrfAi Date of Death... ..R...........,1 19.sV..8
Age s, / Years 4 'Months 3 ° Days Birthplace .r 92 • ..
Cause of Death t G►-t t.# ?./4. . ...... .........
Certificate was signed by c�?1�.JLQ���� d:J..�����i-:t.�. p �7" M.D
Address $...0.....c' 4.1. ....,za �r7c�� ,
Place of Burial (or Removal) *, ddd
(If body is to be temporarily held, fill in,eice later)
Cemetery 43"-c iL Date of Burial 91,M,, . Ai/ 193r
(If body is to be temporarily held. fill in space later) C/
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
��oopn the basis thereof HEREBY GRANT A PERMIT
to
k. R. ...el/ I . ...(7
(Name) A ess)
the to hold tempor l and the body.
( nderuker or person having charge of corpse) (Inter, remove erwiv97.70. [s a how]
Dated., a.eP..t.. .....2, 19..3r (Signed)
�V/ -- Local Registrar
This Permit is sufficient for the Removal (and Interment.or Cremation o a y to an art of the State (subject to local cemetery
or other reguiations), unless removal is by common carrier, in which case a T nsit Permit (VS No. 62) is required.
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