Lampson, Glenda Form VS.at NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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. Registered No............................_......
��++ Town
Dist. No5.4.4..7.Co ty. --iftagr
(If city,give street a ss)
Name deceased..a . . .. . . .. C.o
eac4 thlK ��/ f.,, .Single, married, widowed, '
S . . olo .or divorced (write a word) Date of th..A.. .►.../... ,. 19. ....
Age rs It Mon .... ays Bi /2ce.
Cause-of Death. ... .
Certificate was signed b M.D.
Address
Place of Burial (or Re val) �t�t
(If body is to a or 1 flll in spa r)
Cemetery.. .. Date of Burial... . ..e4.«...1 1 i 19..637
(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 exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have a accepted the same for registration, have recorded it in my Record ' the above stated Registered
N and on MI
, aeis HEREBY GRANT A PER .
to.:.
t v
the to hold temporaril i ,„--- 44 dy.
,, �,,�� � the bo
(I.9 ;ker ) - L: i,4 (,r$i ye,or otherwise dispose of[state how])
Dated... '. ° .,......t... . 19.. (Signed) �Jt .` r�..`�
r / . . .. Local Registrar
This Permit is sufficient for the Re al (and Interment or Cremat7 n) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in,ihich case a Transit Permit (VS No. 62) is required.
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