Johnson, Clyde %': Ie ,,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT •
lilir Thu 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.. Y5 7 x.. Registered No
»........_._..»..
County.........‘7_,..exer."--,-,-)/ Tower'Village. ». ». ...-
(-4trz -C.-, 17
(If city, give street address)
Name of deceased __ _...._._.. _. _.. „...
Single, married,vuidowe$, • ''-
, . Date of Death ''- =- 19... ...
Se ....._..„._„.,. »..Color �.__or divereed (write the wor .„»...
Age..„..J 6- Year ..._.....Months - 3.„.....D ys - Birthplace;_ ...
Cause of Death . „ „„_„ 4
Certificate was signed by.. • . i »...._ )V1.D
Address — ig ' f_ „ _..........._._
Place of Burial (or Removal
s% pare later) _..»_.....__ _.. »
(If body is to be tempo? held, fill i s „ „» �
Cemetery iL,r t.... ,.tl. ti, Date of Burial. . -- ....._..19.......
(If body is to be temporarily held, Ill in space later)
The Certificate of Death containing the above stated particulars, having been prey ted to , 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 n e basis thereof I H REBY GF;S A PERMIT ".._......»...„. --e--..._....»
mti) (Address)
the ............. ... ...._.........._._ nhL... —........to hold temporarily and —......---....the body.
(U a ker or person having charge of co se) (Inter, remove, or otherwise dispose of [state bail)'",
Dated......... „ ....G.L„„....19 Y (Signed) `......." ...1/.,:.
Local Registrar
TlJCiv"`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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