Bushee, Jessie Form 1,S.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt 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.._..A.1Z_
� Town
Dist. No..3.1.1.�:..County . c-t..r rt. Village AA.,ccl
^ _ �� ..'.pyzeLsnis (Welty,give street address)
ur-2
Name of deceased —K ILG.C_
} Single, married, widowed,
Se Ll!St.i..e.Color!.. i..or divorced (write the word `4teletr—iitwr4 Date of4eath ',/ "di 194"a
Ag"e....7.4' ,T�r"_s if Months..., Days Birthplace./.. .%rnr�.•o rc
Cause of Death /.t a,.£.... . . ..., �
://G% j rs< far_ iG,c.,
A' ,,2_.a
Certificate was signed by f,,....,i.C/�r,. sd.-L .ct c,,,F,-c� M.D.
Address —z 2 . r-�r H, �i
Place of Burial (or Removal# Ct#t410est
,(,,,en(If body is to be temy%srrraarlly held. space later) �•Cemetery d��* ++ • Date of BurialcCi../219'�4
(If body Is to be temporarily dspace later)
The Certificate of Den coning theated 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 ,a,�c epted the sam or registration, have recorded it in my Local Record with the above stated Registered
Num.�J�► don the b t I HER BY GRANT A PERMIT
to.... Nt itiu.1a sun—
the .r to hold temporarily and /"`nel" the body.
(Undertaker r person having charge of corpse) ,1y (In r,remove,or gtberwlse disoose of(state bowl)
Dated (Undertaker
• / 0 19'f (Signed).C/,.Rra:srr...MP -u-crirer.•f,,
rar
This Permit is sufficient for the Removalanyeka'Rert of
(and Intermentm or er in h of a bod ns any part the State (subjectqir tod. local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
0=7 59 ' a,�j 7...P am=:vieo 'n' O g an rg ^°.°.ET r°nonno•nn < co.5.a5 -,o.% 05•yN c.r•... 0
-=3. r. c3'n.t0O.�+ n ab»rc• vmec 5c.�'n n .'-•nm+ •u^ n < 3a'-C.::.• . _n on3 ,n^, 0a 'cnzm c"a ° Z
A.,,• al wsa �o0.• OLE', X :.'_o'Yag5nvreoa�"'8 = „„.; ae „mo 7.rEtocow N0zzo ; ; 3, .°.. 0
e? ++77° m ^ Sa =.^no „' e,. •o O . ^ •nn.•a..m•T= = o_°p.,4o'o a ^ ^ = --. 5'c3_vi --./.-•• • • O
ii.K_iC UIIIIIII!4!I[
nno n "offs« •• < , F.ca�oo n: ° a • VC •yn 0 no '0 ... .SOaa,,VJn S,,,.,,.. ',»1ul< � ^ n3w �O I, Hill
i« O_ oan ^: •< 2 gnTsa5=sc - a .< - Re ,t,toO° cn =nap' �e -e Rq �8 ew+ n " '" un5.• E."•_a�•"I EtgPO it's.t:�°i oea�dinn Z_. ,Sc•n • • 'A ° au4n --an ^ a� mc. ' c.aC f „3 cay°. & 3oG.nEo =Q 3 .3 ao �y So Zui 1-3
e. ,.• ', z El8?vcryFan -.wcPS.Z on ...0" 14 "y 5,°,=., u .^°, a$'FP. S0 j�c „� p5'Oc z 00 yo a•u ».n �•=gan-o n ns n --n u aTnu .. O > • • `a0,� .^ —ar.. . o o + F3.T o .. n5'6 �• 0. Fiittic 1 ••n <g-.• n •I
c -i•°..-1 n^ Qr'°' ^ ?? o 33n E." n ^ a.n a' a :e'O + a-n K°: ; ,^»^e ,^,° Nn ^ :, •`0e m2> o ga �uS•oG.yn rng^.a5 .14 ao -•:`gnS.E gn -'5,O aA.o o ^ .. i 6enn I*:
+ R1 �n inn nn . n n 9 � n 0 n'• .. -'^ n < nn ^v-' n , 0--3, , � i 59 >it ; p ✓c ^j�•�
o •nyA n. :cy ,soo'e .la3'�»n RI
n'Ccn, e ?;na3• »�c-,aaF'nrr^ n �-o P• �n•n ZSO
a N,'N ...t ^.or A.-The' n a^^'a a.S 5.+ r..w.nn 'o'N• $noL' °,-.'^ .,az,7c $c _< < -n'om �"
o 0�n a. S o.G o < ua 3,� o n'o_'s� g'Pe„ 5R o ' z• 00. w „ , /,... To ..„ s •^. 3 /d� uS en> i •ca i•IZ• �: .�I•', .7.0
�a n -I SnpCO =>•. /6a F.no_ � ..-� S+ nn .n tr GN a.e C ° N96W r ° -. a •�.
O mYw a9.„, -1 cog q''wc• °0 »3N' e. ns•c3 E.k n s w,o ; .,^ 4$ Ngoo ^• $.aw o _$P" 19 m;o ,; ., 1 -z
n " ' n0 �a 6 =S.^, x5:_^aa'e ° O80 .5,° 5. on np5,-.5.g c.o :0.e n�.^$a Cilte :ve« ° .s -.]I*I
oo▪ n'.e n . --->'r c.°.?'" n -� °c nova=-T^ Ga� sn"�.:-in, »a3•sno a Grp ° a 3' any
3 Ca ny* .9. uy^n • nO n nn 'RnE1 9 " < 2,..' 3n0 gacn -,rt+ � n
y�nF 3 _ no_ an =w ^ 3 R - T,. °'u• n. ,;n ^ no o.E,c• • 3+0 :'.. - 030
orn OR `7° n a ^g y �n:1R � u o :.n, 3'3'n .n+, o'° -.ao•£ nc--=2--.+n . 0. N ; -i- -, c. � Kl rn7
fi 0 a + a w n '4-0e v •a.^3•a ',u ' .c oo •a ' n ° .»-. ° ry 3 u. s°'4 c o.c cn+ y'�1 e f fr n + - Z'-,
_,nn_ no 0n OrH oo. ;,'X- eo _. n . o - 3• •• a ma- n a-n To /t� ""'�
o 6m� " 3oucn ^ aO,^ a'gE n •n. -s° �� ^ o;' °.' ° _^3n ^=6i$ GnN 2m+ tr YY NZ
Ftp
R� Nmv ' ?:' ^ S: '^ -.? S-oSn - uItttllt!11EIiHIE
npc a �.5,Ap ovp c°C, , a h.o S ao -+ n$ny0,^ a ?., 20 n "...'R �� SAC n o ^c.-•0 0 0 0.<25.5I cn . • o c -I-Otr.•nZv"i'- ° ' ...5 ? � ' ^ g ae, z�° '• ✓ .�
• ..= ^^ n F-,a H =0 3 C'£' O ''3 u-ai'' 9 ,8 ^ o r4 v. n o -“;[^. - -� r ° C a L7
n0; -•-"c.^._ ° o mg.f.g g� ' vn .^ SM =.6 3 5.3 ' n c S.n Qo no$ 3 rn mnp£. O, 'o rn
rim 5.... -.'43 _,a5.�,aEO 3nP '; r.:a 5. 0.0Eao R $.-o _,„ u -_.° .. N + 0
4m°. sn=d'a . nd'a -.Fa , -.—, 000., .e$ 5... e..o 3.or 9 m T°.g S 3.S.°° .u'.a. o .n 'e1