Pike, William C
Form VS.Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Pritz.-� 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 BLACI INK.
�„ v@gYEtered No........___...__..�_._�.
,�`/t Town. i•
Dist. No' `i�1.?..County 4 d^ I., "`
\�y • =, D oZgr . (If city,give sireet address) •
Name of deceas .,x. . .ofo ......... ��! .44' -.. ' a ,.f ° 1z. ,
Single, married,widowed,
extsof olon ! or divorced (write e word):. .i. 4-a- Date o eath. ` .. G LOP...
Age.: :'gals. *�o ths. s Birth la a .> •
g �r a �7 Y P <�• ,...
__Cause of Death` .
Certificate was signed by... <<.$,__� __-- _ k M D--
Address eC r �. .. •.. e< ,r...• t
,Place of Burial (or Removal).... lr..i.1.1 .�,....tit
.,• F
(If body is to l�mpor eld,dll in space later)
Cemetery.....' Date of Burial .. ,` 19. .'
(If body is to be t porarlly held,fill in space later) �'
tr
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, 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
Nu , and oI► a baa' thereof HEREBY NT A PET/
c yteu..rt_4_„4.Aovt....
nt ) 'i eddts)
the... . .... ..... . . to hold tempo rily and &X! .. .,,.•..gy�pp� A the body.
(U de ker r person having charge�of corpse) (inter, or " h eri Ise dis#we of[state how]) •
Dated..(�.,....d `' 19...?/ (Signed) . . t�f .... .li•r
Local Regi
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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