Stamples, Harry Form vs.ai. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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. Registered No sic-
�It4cct:." , Town
Dist. No....2E.._.County '2v t e•••2,7,j —.cf 5ve"ret`.r.
or et). (It city,give street address)
Name of deceased 1 r .e a
Single, married, widowed, '
Sex 41, Color." .or divorced (write the word)... Date of Death .1. .L'L 19440.
Age 44( Years.... , Months 414 Days " Birthplace..alzx aeR,.,
Cause of Death •
Certificate was signed by w&.osat(.. .... . M.D.
Address Va. , .,7ft. �.. ..r�
Place of Burial (or Removal)V V —e7 A-re-a 47YT,go„....71 I�'
(If body la to be terly.beld, 0 pile later)
Cemetery Lam--c—nR..,.....�1..,5c.a6LY Date of Burial. ,/... 19.1/.
(it body le to be temporarily belt till In apaee later)
The Certificate of Death containing the above stated particulars, having been presented 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
Numbed oCrinHEREBY GRANT A PERMIT
F•%•• ..... ..r.. , ..r
e u)
the to hold temporarily and the body.re
(Un er or_person
on baying charge pf corpse) (Inter•remove,or otherwise dlepoas of(state bow])
19. e. (Signed). ,_, $
Dated ../!. ( gn )... ... 2caI,Ri ar ttx
" apf4�7ton4 serar
This Permit is aufr-.lent for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other rev_ :ions), unless removal is by common currier, in which case a Transit Permit (VS No. 62) I. required.
e=e -inaR P. 0 o•y 9�x euc0 ^ °4.R =O.°.se- ra=.rR ww^n a^• -4.8 &•m"6'035> Oe Ym 3'^°y 0
_D3 83 .. g� �' ' n c (Sng vaST°; ;.T'n'• Pin o - 3 e n0 Y < all ii M
z: ^ .. -g,cv .6 cE.e,_ < oc - n <ff-e• cat 3.�-a�•an-43 '°�...^.o +nnca0 HEEm c+•
$ ° �'
p =; tn wn5 ' °<_ Nno« ^ ' .. ' yao' ouXs..0 '43• . n^ c 'oagnov ^ o _o �+ec•. 1E a Z°+ w °.. : O
.11.-x .ER 3a°.•-S•3d' .y, n - -° n ° •s p a' ° nnb-ir nE : a6° on< vn $a• � T 0-'0 _' ' VZi
• e'-1 T+ „ o Tn u otas .n <.o - c- 3 _ -." R roX
3 0E0 c'3 .n.Taa' e.2 S n5 < T • ° 2 ^ ^ a5._14TE a-I, ' a ^4 :.4 • -3 0 o -icn t "q Rf
p• Z ,?`�n .y.n Ea�-3 + .< i' c r ..tg An . w gc.�T'" __,-,„ a., az . to z
c a-•n -n a8 `�
g P° • t000< 5-agne'2c&.1° o° z,.R6' t- • $OQ ^;.1r3'EoR ' Ew•3.wa'y 'RCome . i rnZ
a Yay < + c -Isg'n � 4. ! ES3. ca=" .53 °^.^ E T+ 3 ^.-o ;u �pf7 ^ ° 0e I
a nC = AtEEVQ.R ,^.° ° c= '< ro -e ° g'naow 3� H, &:.< n .�. �• 0 1 C„.]
c O^O a" a-ww-aFd5'e•$ wno 614 S-_ + nduyn ^T' S'Inccac�e O rgB Z I nMO
�0 �0 z� �'ocE � 3.5R � R •3'0�+ • 03 a -3 °,C at.° tIL.11 < a. i �MMOcn
c -I gi-I n T_ on n " ^ . y.n1 wisp " 0. =^inn° Z.Ns ...0 1 •l
0 wy n e ° nr0 ^3. g� `o Y1'.o nx3 0 ^ • : w aRnCj- n-.a n'O + w4 + >1 ! ° a.2R7
o mp rip-A ' s -o“ n35' Ro ew5.+ $ ^T° a.R20 �o2.ao rt' * 0 'L' 6'?•E'Q,'a err . •i ^3 )C
e �°r ° ° p ^ +n4^3 aT �Se =.0 a.c.. -R aR S G' u R g' ^ c$'k ems^ C F.o � o ^i. i• �,'SO
i 'i :. 056'g .aa33ea_.n K -wt.° -01-00, ° S " °`c ..oa4o•� �0 -.' t.. as"'C'a � 1 $i uln
2n0 cr° Y�.¢ -.:,, no5.n z- .. ° - - • y w.Q _.nn • n'� Z e , ii
:joy: sy,eo5.@ n .. . .0 es< ^a^ 0.T ° --.^ Rr< rca3 - t-.> ne ,'1°o3 g i Ri yx0
t�`-+nf-ir- 31 doon�"E $ 0'Q + .., aflinnw8 eIT3 ...aro, 'gy 3wgaee.P' 9r' - :I 'A..S9
+ ZDA T " ^ 0r3• 00..35 ijn x'e'o5•^ c^+, $ ='oRS•aw."^a=°3.c.�oR -, -, K .1nln•a1. 7. t*1 it
• Uf 0•• 5.. .i o ,''^^ ^ 'nS.'�nrt-.y 3o 5•esci'_8.5• ° �oc0- ^ i',.,.:,-IR ° trH � I o e: ..1• Z
3m• -ni n + 'cc -•0 ,.. = a0v nau g - S^ k' ° - nRo '.+ -.w. 5.3.snoQ�Y - Xi! .�
n .. on n � ^ nn R ..c I' iyi' a ga an, "n ' O &r1 • 3+ ..g n Y�tn
< TmE n -^-.a°.a gg.=''.3R r- R c E$R 3 ;n S-- a` 3.s •" EcnA R 'E.ye• vo - : ra4.. 0 0
one^ ,^�, Rn": a _,, n:5 + $ a a _.=� 3•-• + > > Enoc _.r.g.. 'Rn0. „j R 5 • ' MMZ'
17 -pr `° n fon * -Mara�3.c5 °.H: c $aan, ' n ° 5:nan$ ga-G"'c o,a u ..1.n(.] n + 2
B-Err-<' `"'3 N " 3RR _." °,R� : o. Q ..n a°rg ^, n < n3 ,-'. " ma'gr.^ N • 'Lir'°" (gyp''Z
: 6 a pRaV,3 o a: C,' tE i y.SS.^'+ " pOo vae=� ig - =,Or 0- °.a+ T f�
a-,Go ti BaNx ay" ; 3 L + rg'a -'e$nR ! , + a, -�_'c 3c.R �` ao5 ^ ca^c-r Zeog :n CZ
� e:ta aR ^04E 3IE... at''^ > > ° §%err 3` 0 r5 =•�ica'aa ^Rec �'.e -io 'Oc i,o�PO 1 rb�
o• n p 3 a co + o : -n `. - ^ 'G aT.._ „y . w Li o f z..e ..
^gip^ .:^ �v�.+d. -"� 3� A nT� � � s � 9y• no �RHno='2«'o `'. -� ° 2a tn3. n
303 E.^cc' : ^AAE.1: 5. a vR4 • T$ �yr 3Y+" < 3 ^ n3 ^ co �'o$ 3 � Q sOE m
"n �° a^ � " " SaTa . wn5 �w :'�<_ d"^E a< aov �S " .rc,e. ^., + m,. O
4m8. 3rw.Ao ng g.tra.R ^n : ! _3oeFa• ."Rsa•=oa.3w4wa° asaAg �g. ao o 41