Lansing, Margaret rote VS 61. 11.23.33.70,000(17.3194)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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.
Dirt. N0.as(£_
County Town,
y. (If city ve street address)
wt
N of decease......
�
OSingle,married,widowed, ---�
Colo-. . ��,._<.,,.,_or divorced (write the word - --Date eat a,,'?'�,,/- -19-.51IS
Age 3 Ye s__._ -Months_ _Days , irthplac .2asS._._ �t..__.....
Cause of Death.
Certificate was signed by..__.. .- _. _ : .
/..
Address__...__.__._._._ - --- __ ._L.__._.__..._.-._.__._
Place of Burial (o moval)_—. _._ _.(/_ll Lan.. - r _........._......_....__.._.........
(If body is to be tem t eld, fill in late I
Cemetery beporarily -7 lh'/c ..__„._—__Date of Burial_._ ----�._ 19_ O
held, fill in space later) _ --
The Certificate of Death containing the above stated particulars, having been presented to me, after careful examina-
tion, 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 o e e basis thereof I HERE
Y GRANT A PERMIT
to . ...... s _✓..sir ?a...�_ //�. i - .Lrrr_d.--t-----
ame) (Address)
the- _. ____.__.___._._._..to hold temporarily .__the body.
( ertaker or perso Laving charge of corpse) r, remove, or er ispose Istate howl).
Dated. - ..L..._. 19- .!! (Signed)- •- _._a. ... _�_....
Local Realmr j
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pan of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which are a Transit Permit (VS No. 62) is required.
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