Chadwick, Jerome v
NEW YORK STATE DEPARTMENT OF HEALTH
- OFFICIAL BURIAL (OR REMOVAL) PERMIT
OWE 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. 6-lP .6 / No. /P
Town ,......e4„....7"4„:(=egistered
County - Village
` � (Ifive str address)
Name of deceased �—
Single, married, widowed,
Sex ..... .. p p Colo dKorced (write the word) Date of D ath 47-7.1 ' `/ 19 /,-.
Age fl...p Years °� 'Months 6 Days Birthplace t.,s---/,/,4,-7 .,e,
Cause of Death ri
Certificate was signed/by 5. ,. , M.D
Address /
Place of Burial (or Removal) � .. r .!
' Y-s'
(If body is to b ;gorily hel4, in space later)
Cemetery �i '� ` ate of Burial /� Z. Q 19 Of,
(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 t is thereof I HEREBY ANT A PERMIT
to
(Nam ddr
the ...... .. to hold temporarily andthe body.
(Un ker or person ing charge of p- er, rem or otherwise-dispose of [state how])
Date .. G
d ............. 19 .., (Signcfl? ��
' Local Registrar
Th 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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