Douglass, Helen Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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..._.-.--.,._.....-..-......
Dist. No County ' nx' Village '
-Of City (If city,-give street address)
Name of deceased He l e P- . I1c 1X:...J Q.1� ?. ..a.a
,, Single, married, widowed,
Sex F Color ,a or divorced (write the word)....itMarx:.a.Y6 Date of Death May....11 1940
Age 6.3 Years 1.0 Months 9. Days Birthplace Qan.sad.a.
Cause of Death Arterio— sciroses of the cerebral vesselo
Certificate was signed by F.• L. Havil and M.D.
Address j 1 take...": 1.1.5 ..,.:,
Place of Burial (or Removal) e a.t..'if.1..a.a...4.0.1.1,a
(If body is to be temporarily held,fill in space later)
Cemetery 5 ....illp.b.axls;zs Date of Burial .I:a.:y...3, 19 vQ..
- f body 4.to be temporarily held,1111 in apace 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 LP.r. .la ,i.. Si =J.A.tQn). . R.a.dge...at.. 1.e.na. .1--e.m1,3..s
(Name) (Address)
the. T X1S�u.x tc.�{fix' to hold temporarily s ,. a : the body.
(Undertaker or person having charge of corpse) ✓�/ (Inter erwise disoo of[state howl)
Dated sia.?:..J.4 19..4.0. (Signed) . fw:y..
ocal eglstrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to an 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.
t'�I'd g,the0w ..wgtA �.rn 0 0 $ so+owp.8n r"° Rtr0►ip•w.1 < fitT6e,6K Opal
VA 6'.... 0
O ze K K o+C O.fe gOXIZ to ., ^r 5.*.0 K #RR Q••.�°3Rg° ° .,8• - - >1 _ 0 �S�: a ..
.Oa.>g m3K ° O agg.29 4' w s+tUN � A K wf 1
tna- w K ° '. a ,�, 'rztrr .wcm♦°KK ° 6 .9tya°.wKte3K�, �f K b'
ZK 0-4'g'4ro a fo p, 'o s sr 6 ° mw < r. o•aly o co0 Wd' ro a • 8.0 • w o K a,a.so .o W °' sr c4—• 0 toy _, w A O . . o Z o ""8
A gyp.(A m w:�'E O ti a i aKo- r00+. to o 03 oo.0 .°.,V� ..-t � � '4 0Q 0 •C K w° ."' a V � p p v ... S/i
it • , Ag ....t'��, ,„•,0 #w � m.0 .N g aNti•ow�'44aa'4 •Q.g ,,.=.=m c6 Cam'- cVO �-.-
'1 .�,'C:— ..O the 0 L3..,°., 0 ""to n -am- ,.K .ti .0.0 rn_� ..< 06 r0. !J ! ! ; !
• 6:H'a w.< R eDE ". • fi!
Ik (. y (DE.f� ,it. i ry h 9
c ,� Z� .5 Ra K Pyn` z�� 0-0 ^ • . w $ °' ""�;�R•• wpO1a'� � C9rn \
•+ a. °� OS.� G �'eo�tq�� A> � rowK_£.oK �, o a° `''� qxp'° E 0o6° .,. � . Ko :.
w �"�,
,$ q C K r °•o w aro�<`,,,° v". '< .. Q w. 0 5 y CD O . p e w to "' mu'
m•"17w Z •w' ° g•w 0 ti'S a3'eoa- a z ° 0 St m alp• GO'O'K g aw I.
ry 1 d --I 8 5-al 0 gE40a i -,'Z F`^ mCA�e0�
o Oro ct � K .. w t►0 V7: to '' f° O co 0'icy* `+ p, C n3•s•- • p.. CO 0k w Cl7
ri
a •I..• I c, g..w+°CK O Ky OOc`o we a. 0 9, a^ ._• '. O 0R. n C�1
o.sxa aw.?; A.Kxe 'Rti ?'.wk ,•ww do _" ., go.�° ° Kp- 6K �i 6t. • o fl=\ P, f-lc k
Cr/ O w e n .— o ., n 0 a ° � �
� .q„I (Tel °.,R $ = p�.K ,.S'. tr9 = o.= g , ;.n ° ., �< o.a°'b 1'°'`Yi• oUtil A. n a dMall-
p _E w K A'p Ka.wO to f9 ro ff <.°=0 to g 8+ "t_.`�= a• `�-0�f 0''�."•_' p- 't4 �:
a . IzIqhn
a Iu,ij!-
il,'C tti
E. 41 a„$0 f� ° O y ° <b _ r�(p�S �p� P'•e K f$' CA •^e c . "may
� .� Ow�nryx .+'i"i „0..1 ..°yH K wg . 0 � feo ,p a O. „.0 .-1,.< o !.� b • r� PI
OIn.nO cOi =ro O.OKRYOx � . 0 ,, tr.'Ntiy::: � m et,0 „ ,...., +w "= r�.. G. ..- ��00 �:,1.f
a.$R. .o-Kg
z any -:a w�- /' ,y La i3,C.::d.11 2 '0 " °1 r �s.0 g t<o-o. 3.A 0 :3 ° n -I '"'ci. ° 'i,.. • • n o
.a..4014 K..O .� "'O.'t° a 7G-�° tUN rt. m ° �Ve." 3 n tae ',+ K "" '" (..Y O $•= 4 «°i,Sde v,'pa.•:= CA T8- P ��Z
Q,R C O H 0 - . g to o ...tc.q :r'". 74 b-'O O E.
�eTt g ~O0•miC'p Sri` `� a -I
a CO 'KCnwpQ y'e {� ` a m" = '..Ef01yy R t° fie o, �e •' G }p�Har .. Z
� , m 0(e- °° te -�".�j3y e • y-0 O r -• 5.G'd. . s 'K ° "''� w,K.a;'a g.0*. o 'Pei
Q0.s p a' ''m 8 b K w .E '0 -"" 5.14 R,. -= K v e.6.0 c s4�'S ? o'R'g 0 '" co)
` a O .-.QtA Wb p'`n f. �•.�-=wy, A4.bT,.rK ° to = '.- - ;.1:15 '° w (.4' -m ► g • _ A
w^' O w �..^' 'p" $ f0.n () act {±�, 0 b OO " y..^.n. t ., 0.e ct= K.0Er VOX
oa '* oro �.. 00 Kn.+0 w0' � tie ...a�'0' w � ,f�DN� fD •�' •°' '3•ry KC. �{�+ ,T° il ow „pi
y4 Zir an ua'� 'i ° ►' 0 o• .. .0 ...�•*F.� ° Rb a...F o "'� o '44 a
;,.*x13 ':0 0' a o$' ; 'tl r� o S:I o•is 0'11: ... P4...,0-. w' 5 P CA
-'. t' o• K �jp isg�eo •n ,' Y +K ogwOo �ZowG`a C ,.
., g °O'n .c -.--gm ,4to nre K wow g � :'iia6•Awo•or►' as q o0
A O�Op x; '`< . -"" 0. '" R 1•,";K S. amp ,; �.A b ;, c w .a•a.O °B 0
ilk tl n p•da bo 5•a � 0':.; =ewe n din 'eM is O C'N Q w£r' Or,tK°-� a.tg'On " �