Haynes, Thomas Form VS.e1. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 CERTIFICME OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No..•
Town
Dist. No b6v1 County 'ivarren Village 78 Park St. , C).Q. . ...EK11. ...1.Y,
or City (If city,give street address)
Name of deceased " .i.Q111 ...-,-,....; ray.A .$
Single, married, widowed
444
Sex.Male Color.. ►+hi Lgr divrced (write the word) Married Date of Death.A)ri1 2J„ 19
Age. 74i Years 1° Months. 14 Days Birthplace Fort Ann, New York
Cause of Death Arteriasc1erosis
Certificate was signed by . 1:1Q.1...s...i....t''.. .0 1.1. y.M.,.•,.D.. M.D.
Address MO.3 Q11...,''a .-1..S,. .ii Q.'ir.. '.CII:4.
Place of Burial (or Removal) i+'0.r.rgr1l ( 4lf1.ty.i. GJ,Sig?.. .%a,.J.,.s.,...:d.e!!r'...Yt r.
(If body is to be temporarily held fill in space later)
Cemetery ' 4n...T'.1.QW C Q .e t SU:Y Date of Burial .i3.ix.i..1....2 :,....194. 19
(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 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 on the basis thereof I HEREBY GRANT A PERMIT
to .i.Q.g.Qi:; .. ....`v..ax:.1.Mt.Q:'1 i3uCISQ1,..,ii.a.1,1Ss :,:J...`�.oitk
[Name) (Address)
the. Linderi..i er L.ii.i.l.l...C.ar:%e.t.o.n)o hold temporarily a inter the body:
(Uncle ker o person having charge of corpse) nter,remo , o pose of[state how])
Dated.x.Vr l 22,E 194:i 19 (Signed) ..a••• '
Local R
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to 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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