Wooley, Myron Form VS.cI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can 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 WRITT URABLE BLACK INK. Registered No__. _9_._._.___
vTown 11
Dist. No Ci G ount G! Wier
fj
�j �j p I, (If ett , lee street address)
Name of deceased.. ... . .r.married,Single, married, widow D
Sez(1��... ''`..Color. .. . divorced (w (teShe rd)Yi4-fF�4WS/ Date of Death 0 �O: 19410
Age ... Years 7 Months..,- 6 M.D.,l4s Bin
Cause of'Death �/- ... CJru`�e+`—ems
Certificate was signcc�N ... . '...til...t..
Addr .,(
Place of 1 (orJ tmoval)
(If body Is tempogir/ly bell,fill ace la �j�_ /
Cemete ily bold.
t
Date of Burial.54 i O.3. 19.1-0
(Ir body I.to be temporarily held.Oil In space later)
The Certificate of Death containing the abov stated particulars, having been presented to me, after careful exami-
nation, the same appearing to he COMPLE E, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hay accepted the same for registration, have recorded it in my L Record with the above stated Registered
Num afro g ro e b ' f I HEREBY GRANT A PE
to... .
(Name) Isddrea)
the K4frtirr—.1 to hold temporarily . ,.. the body.
tulA�}yeet�er o�r��pe�geg�aring charge of ybrpee) (Inter,re, ,o rw dls'wse of(eta bow])
Dated /'�P f/. /.dir 19 H'O (Signed) /i/ t . .
ileal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) 4a body to any part of the State (subject to local
cemetery or other regulations), unless remoaal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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