West, Hazel Form vs.GL 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 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. legistered No183
Town
Dist. No.55. .Q i County Warren Village....6.x...R.i,dgs...5 ...
or City (If city,give street address)
Name of deceased HAX41 A:m1 #rx.'.it't] B weat
Single, married, widowed,
SexFemaleColor white or divorced (write the word) married Date of Death Julie 24a 19 39
Age....53 Years 3 Months .1 Days Birth lace....BAB:Wil ...Mama. elm+
Cause of DeathQl.#.'.oix)ill ik 9f ..e.BCree - 1 MI...s. 4.41f ,.e.;.Ala g...in: emlina1... B.Qt...e.a.rGii
Certificate was signed by..4f..14.0...4Yet 'y$G dermoid...°yet...Will$..removed...3-3'9. M.D.
Address . .....L....Haoiland.,...Gl.ans...Fa11m,....at....Y.
Place of Burial (or Removal) Q1 een lII a.. ,Ns...y.
(If body is to be temporarily held,fill in space later)
Cemetery P.ine...Miaw...Cemae.tary Date of Burial J.t7,l]e•..22y 19.3.9..
(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 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
to .Ja.espk.E.....Regan Glana..Eslla .N....Z.
(Name) (Address)
the Undertaker to hold tempor . the body.
(Undertaker or person having charge of corpse) ;040,
/ / move . ,,...A., dispose of[state how])
Dated Jtine...26, 19...3.9. (Signed)
Local Registrar
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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