Rennie, Adelaide Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir This Permit can be signed only by the Local Registrar (Deputy or eubregistrar) a 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..
Totya ` //
Dist. Nm[.�i.0./ County Z!/.Q/t1/Letet . �Glle6e .. .. . .. .t'R.G '6 1 .3ra4
/� Q Or City (It city.give street ad ss)
Name of deceased. (rpGfilrutre.(t .r.,.t�A4-nQ 4sr. /•p- erzen.e.,Ca
t Single, married, widowed, ye
Sex. . olor or divorced (write the word)../�Cl Date of Death.. r" .BOO 1900.
Age...4.o4s. Years 4' n s ? .I. ...Day , r irthpl ce 1!L '' �'"' i AXr ..
`4 Cause of Death. e►A!�e .*r ..r.. .�:d7J , A.
Certificate was signed by M.D.
Address. . .
07
Place of Buria •r. Removal).... .. '.CTrCN
(II body is to 9.rarny bald,till ce later) vy���
Cemetery....�.eCe.12 e.. (.(....C2 J Date of Burial " tr /' 19..?-0
(If body Is to be temporarily held,All 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 t e same for registration, have recorded it in my Local Record with theabove stated Registered
Number, + ',�/�e • t of I R BY GRANT A PERMI (4, ,, QQ� y�
to 5I L �l "`'o`'°�r�" f l'ise l....!!/...
• ddreu)
the s J rq�e.. ...to hold temporarily and r ... . bowl th bod)
•.
tusto � let halo ge 14t (Signed) ( •n rw seor )
Dated i se. l9 . .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematio f fody to any 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.
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