Brown, Minnie Form vs.61. 10-21-37-25,000(17-3459) I v
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
LW 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 CERTIFI ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No...J .. _.
Town
Dist. No....3.211.County Village At..A-±v
• Jam/ or City (If city,give street address)
Name of deceased �' K-
�, , Single, married, widowed,
S Colo or divorced (writ,the word) r�....Date o eath... ......J a` ..19 ?.
jj J
(17 Years 1. .Months ays Birthpla , °�'- e- '
ause of heath // r,A ? r<.,C � 4.4'
Certificate was signed by .., A.. M.D.
Address M.4 'cY.., N.,.Te
Places-of Burial-{or Removal-) G -efl e . '.`a l £,..N.S Y
(If body is to be temporarily held,fill in space later)
Cemetery Ei ffi V1...W Date of Burial O.at......23., 11.59....
(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 x:A.id...C.,.Sta.N.ZArs1 Glexis...Fallls. ...LI.
(Address)
the 3.th r taker to hold temporarily and $i pose of(state the body.
er o erso having charge f corpse) (Inter,remove,or oc s how])
Dated 19.. ! (Signed . 1,.,, t.°
00 L stray
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod 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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