The URL can be used to link to this page

La More, Lena Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT Car 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 Dist. N ,Q. i Town .q... County ..\lY� Village � � �j� or City (If y,give street address) Name of deceased 4� W�a...✓ll.�L- .0- Single, married, widowed, • 7 Sex..7 Color. WI or divorced (write the word) (i .4? Date of Dea ...' I9. Age..gt.� Ye rs ... Months.... Da s z rthplc , �.. Cause of Death... .. C�G�L -/ .. . Certificate was signed by �i(/ /.....,. ... A.,. M.D. Address.. ,G' e- — 4:P!, ., Place of Bur'al (or Removal)y� (If body is to m one fl space later) Cemete !'',� v�rZ��; Date of Buria ./� 19 14 (If body is to be temporarily eld,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 h e ccepted the 1. ..e for registration, have recorded it in my Local Record with the above stated Registered Nu er, d on thi.asis f I H Y GRANT A PERMIT (Name) (Adi to hold tempora 'y and body. �.ertaker or pe�p n ha charge f corpse) (Inter,re otherwise dispose of[state how]) Dated. /,. ., 19.. . (Signed . �� t istrar This Perdu# is sufficient for the Removal (and Interment or Cremation) of a bodyto art of the State-(subject P ( ublk to local cemetery or other regulations),unless removal is by common carrier,in which case a TransitPermit (VS No. 62) is required. ryy g.'2O0'=A'0.5 " n f, o. O wo+o! L. CoK0 ti tw < 3 - .. d pyl7V op^. ^ 'yV? I.0 iK •y O Oa •' 1 pi C5rg.w "•rna;g � E ~ rO ro Q•2 CO` MO ›.°gMA �o ~ g " �'^ a. ,.m° a 0/ • ii Z-z- ge 'b '0.'2. a• ° '-^ w3 •" q_ -ab ta4 ,v v ^w 0� < K � `rOOtg5, p5olgN221Gn ag.ba'9., a'O ~` O'-V ^0 pp '° dp (p kee , O`a- ww.g ' 0" o ,, r E.o.2ppow , o05cw9. a � a "o , po : . . .. � , . k R V v g• oX941 n0 .4.0 •^ C w n 6 ..... *" ° vpoc2 " ` ga � o�a ax° ia ,� R $ a ] R ; r + », * 8 c'�" � Mawone1 rZ�Cf; p�0 a g'59* D°=05r oZ < Q. aw`-'ia5 :r7. - wV ,.lo OZ• ,11 ir =n;_t t'-ru ° U 1JL G II .,. 5o ;;aE ] .°, g ��gu* ate+ owa Cf fd l 4 rt a .30 •ICY a,to —g O v, ,mot o' os,w•= e, ut Ay . g0 "'° z " 5E'ra''" •, f� 5'e.ro az gom --a. R.» c• y ^ o 0fyir g . �'© . x m0 Q.-0 O o •t .. O w a o %. fP O' 0 • fo a ' m .....p.f►ro ! w [,�l FloVI R.y �` � o.�"O3 ��'o -� , w .. ha ..�► c� wce o +.�e o ,�0to o a '^ao Pooga o oS^43I o'ro • gw05„-,, 0T.* an:..5.fast* eA agei 2 "' 'n ,>Ztm'J • 0 . .?;.• ° K •, fw, �.9.,0 m ry a - w4 :1 O .tip {.R.al. -t ti a...On7 •, a--lit I '': i ll }a" y �y p 1 i ::-.g ww 5-0 A`aoJr* a oi +s-P'' w `� '-� `!_ t~ is _ ' 4. le Fro 5" 1-6-og -g'g.q09-g• :a wr, —RI- t wg?, Fel A-1;1 -1 •21 IX 4 • =° O'gir n p�p o' - ? ,.O •+. N A h'ttkt!iit: ry w.^j a •t or'.� to 205 ", nAC.O. A ba•[ 0 p4, 'fie'NA 1• 'd 4e.-$ 510 , ' • t.j g•`'. i p >PO W �][!!r 5 1 °O A PC'eq `t,ty .0.d, ,i e° 5 oo. 1 5 fn a.w S g o g c f9"«•Z .-t-I 3 �•i• a .? ^Onp' •, �.w N .cy o XI 0q C' Pt .t .. •t ►0 �t t p �0. t ;\ t�t�7.. ° 0 M "t 0~gR.arw.' CCew5g ~ 1' R f.OR::%•cn pn0 naa,f. CM... a. 0' ' �} p Si y� • Or '<nwAa oq,oti. a.o o ..toga. P.a ; f. § 'v r" _ �t^.w 11 ' va �Z�y C !• pMa 0 , O 03 ,,,t n `t , .ft ..,ti w 0 0 LE r5 of .y n, a "t 0 .0i.0.te ,g fo . fo a:'. ..W • r.t T Cil mac. •~•• '. S� O �. a•L• ... T. g g a N • efl gad wont E,,, o ,,,, .., `_en Ag oa.5.4.. +w n. w "� oM O ^go•... '', a. .�.n0tC R� g of~oo � caowo.y�.'o+`$ , _ b 4 0; -0-.- g 0 85 ,-, ~ 5 8-, 0.c -o o.�b � now C7�• �° •J�� e t9 a f� o .t_ Ea sr. t4 O. NMI. d � 'i 5'a:�"! •0, nwtn p p •0i. •a.P�•O Q.�'w 9 w �00+.�t `§.'.C �.