Quickshank, Maxwell Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Car This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (T
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE O
DEATH, LEGIBLY
(WRITTEN IN DURABLE BLACK INK. ,� // Registered No. __...__ ._..._
T9wn
Dist. No.��Q`�l County.. Village��; ,/ e�`��
Coun
r ity (If city ive st t addres
Name of deceased „
p Single, mare i wed, /'may f
Sex.. Color.(..t .. or divorced (w to the Date of Death(,..r[.d[s d. 19r.'�...
Age 1-.,....Years „ Months ....D Birth
Cause of eath .� A� -
Certificate was signed by al/C � '} M.D.
Address
Place of Burial (or Re J ,
(If body is to be temporaril /�> . a '/
Cemetery - /..,.. ..., Date of Burial...0 -/�` 19
45/9
(If body is to be temporarily held;it n op ce later)
The Certificate of Death containing the above state,?.rticulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, Ct 'RECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ac ed the same for registration,have recorded it in my Local Record with the above stated Registered
to
Number �. , the _ . is f I F; CRANT A PERMIT gro .,. , i f6a�
e /Address)
the to hold temporarily and the body.
(U rta r erson ha ng barge of o ) (I e o ,or o e epose of(state how])
Dated .0.19. (Signed)
Loca Registrar
This Permit is sufficient for the Removal_(and Interment or Cremation of a body to any part of the State (subject to local
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