Esmond, Oscov Form vs.Cl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
is This Permit can be signed only by the Local Registrar (Deputy or aubregistrsr) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING ad acceptaeee J a CORRECT AND COMPLETE CERTIFICATh OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No._.ialet ._._
Dist. No...31/.tLCounty Town
Village
/� _ _ s + Cr City (If city,give street address)
Name of deceased ttf ter-ii L
�'�',�orrSingle, married, wido ed,
Sextb4 Color'Y""`L�..or divorced (write the word)... Date of Death �J i97Q
Age „y 7..This /LI...*Months... .- Da s Birthplace... .. :�fa.u.
Cause of Death...!/. . .... X:... �xa{Gro�... . . . •
L/
Certificate was sign by.... F%tvjJ. ,a M.D.
Address '.... � I � t �` .4 ..�1!.. ., . ...
Place of Burial (or Removal)l
(If body is to q�mporartly 6 11 in space law)
Cemetery (,i./V'-r` �(-e-1N' `��Yt" X/. ( s".e°� ' i ,rJs'1 u• te of Burial _ T/] 19...1.E
(I[body Is to bo temDorarlly beid, dlt In spat+44qThe Certificate of Death containing the above stated particulars, having been presed 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 registration, have recorded it in my Local ecord with tl�y above stated Registered
Noum r on e • . thereof I Y NT A PERMITS / /�y�/� /_//�
the fnn qq ) '
(Address)
Dt .... .... .UrrA..w! old temporarily and.....At-1S. the hod}.
(Unde er or non having charge of corps) (inter,remove or otherwise dispose of(state howl)
Dated 1 .1- 0,...19ac (Signed)..te.ecv tt...ecQ,. 'te r
.1s' 1 hitrar
This Permit is su cient for the Removal (and Interment or Cremation) of a b y to any part of the State (subject to local
cemetery or other regulations), unless removal 4 by common terrier, in which caw a Transit Permit (VS No. 62) is required.
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