Carpenter, Willard I`.m pc.Cl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 • CORRECT AND COMPLETE CERTICATd3,OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Q Registered No.. JJ f�/
Tannr
Dist. No5649/..County �f.".. r Village (.JI.. ....
/�� �� , /J Or City (I ty. give street address)
Name of deceased lIV iG��"e'r'r'1 r (`
',/ Slagle, married, widowed,
Sam. Colonel ur.devereed (write the word). Date of Dea i 194//
/ rr y
Age it if' Years. (C 'Months «. .. ays pl?ce.. ...o "nr.
Cause of Death .. .e,,, _
Certificate was signed by i •... . .... M,D.
Address /.91
Place of Burial (or Removal) ^r/w+-
(If body le to tie temper held. as inApace late 2!/
Cemetery C/ (� D to of Burial.. .. ( 7 19.T/
(It 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 he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the sam for registr tion, have recorded it in my Local Record with the above stated Registered
the o E EBY GRANT A PERMIT
Number, an a t fb
14/St" • ft/XIA.
to
(Under a ' Zy/
M1 Ing ebl ddrees)
A . . ... to hold temporaril the body.
urg orpse) �(I ova or at wise se own
Dated 9. � (Signed) C
' . Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
tne
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