Clements, Frank Form VS.81• NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dr 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.._.24..t.'___......
Town p
Dist. No... .Q/County.... 4.11Jtr`ti.,�. Village
o City (If city,give street address)
Name of deceased vf'fw�t!fd.....t.....
f / Single, married, widowed,
Sex.../7- ` Color 1• or divorced (wri e the word)... . . ...Date of, eath.. ..2••� 19. 4)
yy 4ma�y�//++
Age..LP... Years... Months. .� Days- Birthplace °/.a. V f�rlt...rl7...
Cause of Death..... :Zfg.. , `/
Certificate was signed by • GL MD.
Address ...
Place of Burial y Removal .. .�• .. ..irizw 1.e' 4 �-
(I1 body is to be _., 'raril eld, in space r)
Cemetery...;- +*. .� : Date of Burial..... .. ..2 3/ 19 G
(If body is to be tempo 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 egistrati. , have recorded it in my Local Record with the above stated Registered
Number •d on b:s i }1 :Y GRANT A PERMIT 'r
/ (Addre
i i'�g� r' rid the body.
(U erta r person having charge of cosgge) s �A �� .. <or otherwise dispose of state ow
Dated.
o
Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body t 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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