Scoville, Elizabeth -imaaso,
Form VS.Gt. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
cir This Permit ten 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. Regi tend
Town e -
Dist. No..15.72.19/.County (772.a../.2/T-444, Village •••.*--0.../
(If city,g re street address)
- cast:it or City.
Name of deceased *
Sex . - oloi1411. .. Ivo'rmceadriej;itvetiddotew •Ord),64396..t. Date o eat tide-e--4 is, ,y9
Ag 7 ..fr Ye- 4 N1on s ia, „Days Birthplace
iegaia, .
w.
Cause o Death S 6.zazt a
A
Certificate was signed by • -0--ed M D
.a.
Address , i
Place of Buri er Removal) -#.:
(It body la to beirorarlly bgld. n space latea) i
Cemetery ' ar-SFY ,.....W.(,)•-• / Date o BurialS •2 er 19.1/4
(If body Is to be temporarily held. till In spare later)
The Certificate of Death containing the above stated 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 cepted the same for registration, have recorded it in my 1 Record with the above stated Registered
Numbe and on the b isttler laBY GRANT A PERIM
i
Ja-e& 75,
• m Address)
the to hold temporae and the body.
zr2(V ker or person having charg=lale) r erseeRe=rlw])
-e---C., 2../ 19. (Signed) to any part of the State (subject to local
' •
.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cr. I n) a/741641
cemetery or other regulations),unless removal is by common canter,in which case a Ansa Permit (VS No. 62) is required.
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