Peterson, Grace Form V8.6L
NEW YORK STATE DEPARTMENT OF HEALTH ' -
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W 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 URABLE BLACK INK. 2r
egistered No.. �- __...._._
// M
Dist. No.. (�tQLCounty.... dr-illage .. . ��� a" -•,-
(If city,give street address)
i
Name of deceased... .. ./.lv,... . .. . . . .. .... . . .. . .. ...
�Ql Single, married, wi ed, /
Sex.... Color...- or divorced (write the word) ....Date of D ath... . ....,...,! ✓... ...19� 11
Age.... . ,'" Years / Months 4 D s • Birthplace...
Cause of Death �-•' �� �e ..�/ - .... . .µ
. . . . .. ... . . ..
•
Certificate was,sign.ed . . . . ..... :. . ..... .,..,�.... ,�._�M.D.
Address ..,
Place of Burial o emoval) .. - .. .. t .e
(If body is to be t rarily held,fill in sp �-p
Cemetery Tt ... .....dl�„ 1�..� r`1!,►vl/ • Date of Burial '/�G� --e.,)• / ! 19.' r
(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 appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ac ted the same o registration, have recorded it in my Local rd ' the above stated Registered
Number on the • �',a EBY GRANT A PERMIT ` '/�
to j .... 6.-Z r
(Address)
the to hold temporaril,
taker or per laving charge corpse) p '.� �I,(Inter, ov pose of[eta howl)e body.-
Date . ..c.. 19.. E (Sired) �ilc% .r .t�..
°cal egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of State (subject to local
cemetery or other regulations),unless removal is by common carrier.in which case a Transit Permit (VS No. 62) is reauired.
oyn 5''; -° SP 0g�Vt.00 -., 2,$'gwo•°. •$ r'Or"oo').t o < o 5,?:s .;a' d;,yto 6'^^ C
1 n5 " as g.�a Q• " .....m � na4g ,=o -18 � f°o -°, ° tea Yw C a2al a K7
Pt. '< .-.0 •" Cl w .-I a. ::0•W E.. 0 5,,, c 5.0 c .- 4i r� " g . g F..0 O .•:a•" P. W p Z " p C, p 0
a y y < $ Po O'4. y pP. a r, ran ..,V^}}��.�" rt.- C a. O "in S•w P..1 f " Oa p v :'"'
�!1 OP.w g ° " y Oy°r rP8 " n'<a �rnTii.'. O ° ''''' 8 < w " ' aaP'P.N °I §.. =it m
a MO M a w N O fE .7"• 2• A ° a.., a .<. a A T y 0 rD p• V p V
R„4= na.o goaNw " .. RE *2o •ky � a a.a., .gam °orr' �Tl _C..a w
,.,,..-....cog .w� SA ^ a O ° A ° `1. A N O o n < w .N, b N k : l',�'O -.�" g t G.a. 9 4.2'8 s e co w e '"' *5.O F°gin 5.,st'..r�r*.6.na.n., .* 6.4 '., A k n 0 HGa PO
! Ili
$e Z S s ( E ra•a--R w o a w Q• •p i 4" o n ti N•a�'.a`,,�'" arr "y'y� S.(ai. •r4 A ni O. �yyIy��'.�'�it� ow Nom ".; i� !Pi
� �•aarB � �.g aayp �NfCP�'� f", yw a4o � �' �'��.N �N,'��'�'.�, ,�I a • 9I �•°,..1 yryry _° •-•w atA." $ IywO � � o wC 'w a NNra yP �i pQw .* ^I p v a � ^'"'ic?: " � ° g W"�
E.Pi,p x -wit " � ".EA.< a'z °"s pKo r4 g E , »,y4*q cn n p m• g y C gj o'iw, 'may 8 c AK7
x0�p oa °�x 'w" a•o' wren 5.25'a.*4 OEff•n a.m y °' ,", eoya ,,y � 0 C75'<�» ,1� LcrI.!1
2.X ; »a 04 W g o °,f°4°C o'g :: �'n°0 5.2 ,111 , a CoCo ID ,, 0 MI rkkA r•t0 •0 am:, E. - 9 o ^ Q rlTi
CA
Qi._, S r) P-.o " =• o p'" " '* fin"..pr.'^+ 6�• R' w ic' " P•�•O a ^ G'i, y e i0 Ep p ' i" ►�y m
A WA On•ba .^a A ,•'gp 'OOhN '3 rG lP yN '..�nrD �,*+ r�w• .^f -� � O �f wp ., a 'r.3r��"" a: >ti�
x a,, ." a•_. ..k'�! a wwk3 " ' 'bo f 2, •1 ° g *atop•"* ° Z 5'myag gn ^ice smi.eX
7 O �n °.,�.�g '" rwi ''°, N n �' 'r r0'+ O w .oy »,rSo o .4 cal �.. a° 0i OS" a m :►•art 9 p.m
"ef.j ,II.
. y (.0 , 0 . ° 2 r"e �'o o rycr ,.., 1. ro , 0 a.$. P'd "- “ o ^
S{o » n.tiIi
w g, H'tItLiL[I
EJi1k'F
l ;I11ift
a'b ..." .�� o oNN °: ... <Q-gOo aoa-- �'." ,g—o A�-a9•� " -i�J' ° fin N"', ro f. a .+, °i �N 1�f 6 5.5," co r" I„ � .,,C° �9' a t" b °i
yt"n "w a. ° O ..'O a r� r) �'•C o "� u°i <'c! " p� rrT�i ' w.a.Cr�fM 'io.p 01 •► O .. IL
ZZ .. 5 A a'O S S*tt W.+..," a 4 ° O O ro .1 < N ro ro " ...T w �,a . `< ro ro iL ^ .� O� �. Pi M
a Pn W w ^ " fo S...tg " " P� C� O O rt O O S C C�
1.3.4* `° c=a " ..o Nreaa -'o n�e+roa•- ire gao < :rdc'o.•.,A;-, , .` o°+y �./Oa00 . >4
n •04 S N " ro N N in' a..." ro " SI m'•O'A 3 p o
2'H r @E'. � or5 . P.,a '' �° r°o '..` Veialsg•g 55.rtoo 2.5gigga'CC'rI64, .g.p.e@.r�" « r.o �' 0�.y
A S.nyC P-N' " ° .R 5roa 5•N " C .:O .a,. oGMryyN N N Cn•!w .g. v VLIG
O O C�' "`"" p."•w rt g a" 1 1^, O S p :4-3 i .. p• " O g y. O O a a w .r' M��.
10 Al rb 'q '+ :+[C OG ri .+ a'Qj O ''3 rp E rp ,F'JS�'_"'a...O','J �"'.� w 17 'al [j 2
C Om ., wArP o•43 ;- a aNa „',.$ Pitt rn g " g•9N < n0ae1,-3a•. 1,° ..
01. Q f° ti" n00� o^'w' 5-0., 2,. a 'ern r° " Oy � � ."..e g Sn �„p p1 -Iz
p 6 w Nob " w o " a. o.." " o rP < S g' w. ,y a ».
gg, o 9: ge-g `0ao'3m� a � G.,...a-g.,, g cr'09 �, '^o ••wo r"aw »,- » (wp 5� =ap�" � �A
Ep fi p P� '--l.O,8 0 . - 04 w P." g ° O," 0y ry as,-,-. 9 b " _M »< g .... � , .,_ z.b.�" O=
n ^ u, P.M P1 " a e 5�" w w rc " 5.O tMf ry C �'9 sP�O Cj'.e y o '�.�
at-g o.'g �O!Si• � ° OQ :11 5' ° °a$�•oat.�•(r'g"� t° '- o'*E'-rP, • n' i';• a < * "No, '..15. '11 op
A w * r•• w -.• pa—,.0
M2 M•• .' •`.a^ ° ,.,. " M a•'^C'•'• O rw1 • N �•a." E PAS /fir
TAM. 5,P �.'..p.y ,••.. O C a !Oi .5.4'4 o a'o"' a-��• ›R'' O "t o A N•A .oy n `Za•R.o'r"e ".e Cg[+ o c2 . vi
.Mg'--, a a te, s. �a ,r, 4-Iy .-�rN8.W g ft 43 G * = Cr° C10 ,0 or'Oo W C7�. i°
c. " "c. try.Stn' w a a Wp•M . �. aN C.o e4D a,o'.p� rai N cr.•
rep .*y �� /v Q
A�, o w. ' CO wCa. Eta
•ni. . +two °aq' �Ery � OPp'wQwT° n Pt�P