Glassbrook, Martha a NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tW'Thu 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, LEQIBLY WWTTEN IN DURABLE BLACK INK. pp
Dist. No..a�. G 0 ......._._ V._..............._..
/,� Town
County_` -._.._..__.__._._...... ...........__..._._....._...__.TilFaye_.. ......_.._...._ ...._. .-.---__....... ..__..____._._.__...__._._._._
�p (If nr. awe same salons)
Nameof deceased._._.__ Ze r.�l r_- ....._.._._..._._..._._....... ......_...._._.. __-__._....--•-•-.--.__._._._..___.
Single married, owed, 1,,, n � _
Yeagautc.._..ColoP or divorced (write the word ._Date of Death k. J__ 19.4...I
Age.1 ..._.__._Years_..__...... _....._. _ \Ionths._4_f_.._Days Birthplace CCCCJJJJ__._..._..__......___.-_._....._._-.
•
Cause of Death.. . . 1
Certificate was signed by.._.2_ . .. ... . . .. .1. _-.. -----------M.D.
Address- ._ _ _- __...__............. . ... ....... .. ... .. . _.
De
Place of Burial or Kemoval)__.....__._ _..__.. ._.._ .._ __. ._._...._.._..... -_- __.____._........._.___.._ _
(If body is to be tem n held. ill in Me later) pp
Cemetery__. _.Llwt s set _ _.._- .__..__._._._Date of Burial . l�_._._.._..._19 't�.4
(If body is to be temporarily held, ill in 'pace later) -_ --
The Certificate of Death containing the above stated particulars, having been presente to me, after careful examina-
tion, 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
Qp�the basis thereof�rI�H/ERE GRANT A PERMIT
_Sl�G'Jtir_z:Aiec—Ir _..f..].. t aRr..tt� •_.,_... ....._._._....._.__._ _.__ ._ ._._............... e_._.__-__.._._.._.�..__..._.
. to
�L tN .) ho24) f� a body.
the. . — ak.._fi._..�__a_. ..-- _...to hold tempora jJ • and_._...._._.._.. .. .._ .( am)
ID 'raker pr parson aving rhuge of sp�ryryea») 1rW` et, re r oA 'se divot* of [state bow)) th
Dated- �-.--.__._._..19..71L`.I0 (Signed)-
Local-- .. -._.__._._...-.-.�._._._......__.
Reelsvu
Th ermit is sufficient for the Removal (and Interment.or Cremation) of a body to any pa 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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