Van Winkle, Sophie F .mSe. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registral•(Deputy or subregistrar) of tha Primary Registration District (T
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATI
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. / Registered No.
Dist. o.! v I Ccanty J } ..---
Village L
O �/ �, or C,t)2 , ..6., <tt., ,glre reef address)
Nam f deceased %"G� // R/ .t!{r"
ir-- 0 "
Si le, married, widowed, (jC/ vr--- /L
Sex ...Color or 'vorced (write the word' Date of Death a f .19.
Age J....e< Year _ 0 Months / Days p Birthplace S.lr...:4 6r.11..,,...�:..;.
Cause of Death - a w. .
Certificate was signed by .. 1 ' 2
Address
... .... ..Place of Burial (or Rem al)(Ifbodyis btell In :::!: 1 ! 7tii. :
�/ _�
Cemetery • 1 C I?ate of Burial �!' rt2 19.
Of body is be temporarily Geld, fill In space later)
Cal.+- a�^s� � el
The Cert n cote of Death containing the above parttcula having been presented to me, after careful ext
nation, the same appearing to he COMPLETE, CORRECT, ND SATISFACTORY AS REQUIRED BY Le
I have accepted the same forcregistration, have recorded it in my Local Record with the above stated Registt
Numr, and on the basis the
REBY GRANT A PERMIT
(Name) (Addte�
the to hold tempo rl and...1/ . l
MI k or on baring charge of corpse) (Inter, remove,or othe tact ct(state o
Dated ( I' 19 (Signed j... : . ..:.YY..,.:"Q----e :' . ea 7`G ..
L - Registrar /
This Permit is suffcient for the Removal (and Interment -Cremation) of a body to any part of the SSIRe
cemetery or other regul.,tions), unless removal is by common canter, in which case a Transit Permit (VS No. 62)
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