Van Denburgh, Gertrude Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ta' 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. �/Registteered No
/ / Town 9)- �e--% �Y1... .Dist. N� !1.! County.. . ...�t'��.G/� Villag .
p or C (If city,give street add se)
Name of deceased... .. .. .. .... ire4!L., .
ingle, married, widowed,
Sex.t7' Color/ r divorced (write the word) Date of Death.did./2-• // 19.9/
Age c.1i.I Years... .../,/... „MonthA....Z..Z., Days Birthplace
Cause of Death ,—
Certificate was signe .. .. .. . . . .. .... ... .. . . M.D.
Address •
Place of Buri jro m al .. y7A...44.0,0 -7 / .
(If body isA e . eld, 11 in e later / � ?�
Cemete . (-- - Date of Burial...,*ef.f.CZ.., Z 19..4.q
(If body s o b tem arily held, fill in space later)
The Certificate f 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 a pted the same f r registration, have recorded it in my Local Record with the above stated Registered
Num nd on a�iihereof I HEREBY GRANT A PERMIT
'",:v, fiC- f...,
e) (Address)
the. .: .... . to hold temporaril the body.
aker or pe oning charge,of corpse) I herwise ISO() of[state how])
Dated,. . ,Z.g 19i' (Signed)
Lo Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
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