Potter, Richard Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
•
OFFICIAL BURIAL (OR REMOVAL) PERMIT
nr 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 WRITTEN IN DURABLE BLACK INK. Registered No a$-7
Dist. No.i.-.441 County 2/reeic:r.-Sers-t--' Village TownVli StC 4 r. 1?--,a taA
f
1 age.
r City (If city,give scree address; Plat"
Naine of deceased.... Ge.ce/7 -°
. ..., 1 •Aingle, ma red, widowed, •
Sexitiarle—Color...7112 th divorced (write e word Date ofiath 2 7-44
l 19 90
Age 0 Years ,3 M nthsrio Days Birthplace.. --&-eyseyer>1.490r4
Cause of Death
Certificate was signe l y. - c::?.. • \1.D.
• Address.
Place of Burial (or Removal) 1
(If body Le to be te rarity held, all In
a7Hlater) ‘21111374-.
•Cemetery... . .4r........e.,. Date of Burial.. 19.erte).
(It body la to be temporarily hel U In apace later)
The Certificate of Death containing the abo stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPL E, 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
Nurnberg:1z%ogn2e Vs theceof I HEREBY GRANT Al'ERMIRcieza
to z 71aPild--
(Name
the ... to hold temporarily an . the body.
t raj:7 r pie.ittat c barge of corpse) Mir/roost ofietate howl)
Dated 19..414 (Signed) Mae'
' Lot4T1/tees
This Permit is sufficient for the Removal (and Interment or Cremation) of • body to any part o the State (subject to local
cemetery or other regulations),unless Yemeni is by common ender, in which case a Transit Permit (VS No. 62) is required.
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