Cavanaugh, Bartholomew Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT •
Chr 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. ....._
Town
Dist. No 56.01 County Warren Village 12..8...�t'arm . ,S.treet
or City (If city,give street address)
Name of deceased zartbiatMagw tie.
Single, married, widowed, 0
SeSeminoleColorri1u±e....or divorced (write the word) 1ncarri.ed.,...Date of Death....Ap il....2,1 19
4Age..a9 Years 1 Months 16. Days Birthplace...Glef1.S...F.a11S.:...N.*...`,.•
--Causg, Death....Ca head...Qr...,P ncxe.4 .... ..ma nt.aJ..... .£ ,ilure....7....days
z�
Certificate was signed by .Dr.....SauJ... a
Address G1.ens...F.al7.s.r. ary
Place of Burial (or Removal) T.041,...o :...geanshursy
(If body is to be temporarily held,fill in space later)
Cemetery ,St JP.:.a41plIcal?Us Date of Burial April..24 1
(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 exat i*
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 Harold CR Stafford Cr.1.Q11,...k: S
(Name) (Address) the body
UAd.x:�k :r to hold tempor - and Sinter
(Undertaker or person having charge of corpse) (Inter,. move e se of w])
Dated. AIT.7.2....22 19.4Q.. (Signed)........ f,
De mj.py Local Registrar t
This Permit is sufficient for the Removal (and Interment or Cremation) o a body to any part of the State (subject to local
cemettv or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required..
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