Lashway, Mary Pr
VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
-.. OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Ton,
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-2 r
Dist. Nolei...County 4 aireireten--4. Tuwn
Vittsge -•%Cgtfel? 5:7?-dist.
or Ci Name of deceased (If city,glee street addre ) -
ar%ia -VV
j, , S' gle, married, widowed,
Sex.e.21......yColor...0.1 • or divorced (write the word ..Date ofertIS id& et,
Age 741- Years MorOz 7/ Daysv Birthplace..
Cause of Death
Certificate was signed by a Artati-V-e" M.D.
Address eh' ri,
Place of Burial (or Rejnoval)... . . ..
(Lf body Is to In siginiorazilebel4A1 Ide Woe late
Cemetery iftdowag... 71.,44,44, Date of Buriala-rea 3 19.6cd
(If body b.to be temporarily held,fill In apace niter)
The Certificate of Death containing the above stat 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 sic ted the same for registration, have recorded it in my Local Record withe above stated Registered
Nu and on the b REBY GRANT A PERIrt. 4374 at!
to. ... P.ie tc
the (#0 me)
to hold temporaril (Address)
the body.
(02 ter o
Dated r priest slog aargetrere) (Inter, o , se disoose of Istate howl)
.4reer 19 (Signed) wee—
al R
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any 4n of the State (subject to local
cemetery or other regulations),unless removal la by common carrier,in which case a Transit Petmit (VS No. 62) is required.
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