Lemery, Jules Fnrm rc.Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
s: This Permit can be signed only by the Local Registrar (Deputy or subregutrer) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CIIFI 7 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered Nolj
Dist. Nts. .417 County 1'gc Q Village •O d / esae<ger Ce rt-4— f
teireee-ar/
Jor City (If city,give street address)
Name of deceased Or/ at
,�/ ,.�/ Single, married widow /,,��
Sexalit� o-Color..... ..J�( ..or divorced (write the word)..�� O Date of D th.. 19..F.$�
Age..alyl YeA.�r��,.... VI o s ,2...0 Days O Birthplace... . t.... �
Cause of Death.... .. : eft .. ./.�rzvy
Certificate was si b . • /
Address.... ..
r /7
Place of Burial (or Re .. ,,. mot , , '
(U body 1a to be tewpora 77 el 1 apace later)
Cemetery. . to of Burial(y� ....'i:.w- 19..t/
(If body Is to be temporary eld, all In space later)
The Certificate of Death containing the above stat particulars, having been presented to me, after careful exami-
nation, the same appearing to he 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
Numrp and on the b •a t re I HEREBY GRANT A PERMI� �� 0
to... . .. rim / Gt4!07t .... ..
ame> udswan
the to hold tempora ' nd the body.
( dertaker et person having charge of corpse) ter,remove,or Ire !ptaa D_
Dated . •: .2.Z.- 19../, /)/ (Signed) .U.. Registrar
• Permit is sufficient or the Removal (and Interment or Creme on of a bed any part of the State (subject to local
cemetery or other regulations .unless removal4 by common carrier,in which case a 't Permit (VS No. 62) is required.
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