Harris, Cora corm Vb. or. NEW YORK STATE DEPARTMENT OF HEALTH- - N-_
OFFICIAL BURIAL (OR REMOVAL) PERMIT_
sir 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, LE =J� Qj�'EN IN DURABLE BLACK INK.
Dist. Nor '//// wttageceee......4_4....c.„ tered No..
Town
Count � -1,---
(If city, give street address)
t
Name of deceased .._. 4 _ _.. _... ....................
Q�, Single, married, widowed, —
Sex .. _. ...... ..,,,C� tielhlo .._.....or divorced (write the word) ateageirso,Dat " Death...7 .,
Age.-.....„_.. Years AP Months f ays B. hplace .. ..., :.. ...„
Cause of Death
Certificate was signed by „ .... .,..... .. .... M.D.
Address _.............. .
Place of Burial (or R ••aval) "621g—c—c.e .
(If body is to be temporarily h .i1 in space 1 r �
Cemetery to of Burial C__ � . . .. .. / 19...
79
(If body is to be temporaries fill in space later)
The Certificate of c eath containing the above stated particula , having been presented to me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ac ed the s me,•r registrati , ave reco ed it in my Local Record .ith 0.e above stated Registered Number,
and o asis th / TEBY T E Xc.c.a.,
.._to
(Ad
the _.... .. ... f. to hold tempor, and the body.
Un ertake per ng a of corgi) (Inter,4 e or�� o [state how])
Dated 1.. 19 (Signed),.. . .' T .,r:: .'. 4...._............
Local Registrar
Permit is sufficient for the Removal (and Interment or Cremation of a body to any part of the State (subject to local cemetery
or aai "` Lions), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is:required.
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