Lamphon, Minnie i- -_. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t' 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 ( b 1/ County Village I6.,...*
C )-(- ,
or C. (If city, gdress)
Name of ceased
1.1 Single, married, widowed,
Sex liqolor lLl .or divorced (write the wordLav to of D ....ttp.Q..... 19 /
Aget&Ya ? - Months 1.I.. . .D Birthplace.. .
Cause of Death �A
Certificate was signed by • l Yl . M.D.
Address
.. . . . .......
Place of Burial (. Removal
(If body is to be temp. :ri • held, e t r Cemetery Date of Burial 0-1.- l�3 19 ,l/
'-1
(If body is to be to ..orarily held,fill in epee ater)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearin: to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have •-pted',the sam: •r registration, have recorded it in my Local Rec wi the above stated Registered
Numb- d o bas -••ereof I.HEREBY GRANT A PERMIT
to ' ` •
r li
(Address)
a e
the �. .. ' ..to hold temporarily and the body.
(U i••h:ker`or person baying charge o corpse) (Inter,rem ,or therwise dip e of sta e how])
Dated ,.. • ,c)--I 19.... v (Signed)
ar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is requir
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