Smith, Royal 0
NEW YORK. STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ow-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
DE(TH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. NG$ .67 Y Registered No..
Town
CountyaleaAeSereirer Villag
, or at (If city, give street address)
Name of deceased.. ....... ._. ....._... r'% %s% `��� _.._ _._....
1 Ingle, married, widowed,
Se , ....Color .. .,��1iH16�16r divorced (write the word)l�e .Date of Deat .. .. .. _ s�9.9,
Age_.. .-,x ..Years. ./1 Mont ,1l Days Birthplace t....::. .. -r..ear......_.. .
Cause of Death.. .
Certificate was sign d 4...... iw�e BAH-e-� M.D.
Address. ... ell!`.. . ... . ......._..
Place of Burial (or Removal) .._.....1-f _ rmeshsjlLietis�l[...._CarSgmer
(If body is to be tempo hel s ate
Cemetery d�„ ��y �Lws� AO Date of Burial'7 .eg /. 19.3..E
(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 the basis thereof I HEREBY GRANT A PERMIT
t4 ... .... .. ....._.. T?_, ..... r P.- !- —
(Name) (Address)
th to hold tempor • and _ ..the body.
e or person having charge of corpse) (I r„ or otherwise dive*. of [seta how))
D,at:: .. . .... . ...2. .......19 y..... (Signed) _ ......_._..
Local'Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part.of.the-<Stete"(subject to local cemetery
or other regulations), unless removal is by common carrier,-in which case a Transit Permit (VS No. 62) is required.