Neddo, Lucy NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
allr 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.0 Registered No / 0
County. wG -t._- Town
Ste, � or-City- (If city, give street address)
Name of deceased. >1 - .vL E. -o
i Siftet, married, widuwed;- • d
Sex Color IA, or divorced (write they� word) a?.,�Z�-x..�+.rg.. Date of D ath �-`��. ��� 19... ..t
Age 77 Year 3 m0 t s ,ll Days . Birthplace..„‘.:irl-�-e-Q .� 'a!_... �.t/
Cause of Death. .. . .... .. .. /�. _.
Certificate was signed by �t✓ M.D.
Address
-WY
Place of Burial (or Rem val
(If body is to tnporarily fill in space /1
AZ
Cemetery. ,�f(Fs ,.... . :(��t�(/- Date of Burial. 1�-Ce -,l6 193
(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,
an ton the � sec I HEREBY GRANT A PERMIT /����!B „(6'Y �� 4114.
to. .tom ti
(Name) (Address)
the to hold tempora '.y and....t4 the body.
(tt�jt�ertaker o rson having charge of r ) (Inter, remo a otherwise dispose of [state how))
Dated eL..1..e.,e. X 19.J (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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