Tregise, Olive Form VS.M. 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 CERTIEWATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ` gistered.No..... ...._
4 v/ Town
Dist. No County.... Village.. ash,
/� or City,
(I!city,glue street address)
Name of deceased 62.--
0
ingle, married, w' wed, q
S olor. or divorced (writ e word rt .......Date of th... 022 19J/
A 7. Ye s Month Birth Days C�a�y lace..
P
Cause of Death yam.
Certificate was signed M.D.
Address
Place of Burial (or Removal)"4-e. ,.. .. ..
(If body is to be temporarily held,fill in space later)
Cemetery Date of Bunal Jo 19`3�: .
(If body is to be temporarily held,fill in space later) /''
The Certificate of Death containing the above stated particulars, having been presen ed to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have a epted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbs and on the si leer}eot EBY GRANT A PERMIT
to.. �/J l,T ,
ame (Address)
the to hold temporaril the body.
(u take r person having charge of corpse) remove, rwise dispose of[state howl)
Dated... 1931 (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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