Chadwick, Baby boy Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr 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. �y Registered�� te� No Z _2.___
Dist. No. 41.County `ri..aCGLQ!Y..4,.., V9,11age.... 04.1.G(,d Z •-....,
/� L O liy (If City,glee street addres
Name of deceased 0 (:/.k =f ,,�i� ' Qr
�%� _ / z.. / DiSin e, married,/widowed,
Sex. . . ... . Color f r divorced (write the word . . Date of e 4.. ..Z..2,.. :...19.�.1.'.10
Age Years Months Days/A, .y�est.Birthplace. l..�l:. 7.2j,
Cause of Death
•
Certificate was signed �Z .. _ .. M.D.
gn y .. . ..,..
Address. R�.�pL - T.� • �J• ie7.... . . . ...re,.cctC..49.,.
Place of Burial or Removal).... .. U
(It body la to be warily held,q space bats)
Cemetery ierrr..t+- .Ri4l.be!., a:G..(.1.ti4t.n Date of Burial.. ya 2..3... 19 hF..'.
(It body is to be temporarily bild. 1111 In space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local R rd with the above stated Registered
Number,pttd on the ' thereof I HEREBY GRANT A PERMIT e �,1
to �J�J
(Address)
the to hold temporaril • d the body.
fund r or n rin orpse)cbargenc (In , 1 ayywee of(state bow])
Dated.. Gy .. 19..7...CJ (Signed).. r �Y
Local gistray
This Permit is sufficient for the Removal (and Interment or Cremation) of • body to any part of the State (subject to local
cemetery or other regulations),unless remould is by common carrier,in which case • Transit Permit (VS No. 62) is required.
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