Prouty, Charles Form NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
LT 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.—._ .)._
/; Town
Dist. No...3a2.a...County S.f..1<!,!teres,r Village
��� or City city,give street address)
Name of deceased digi 4 7.lw»tmek
Se> & ' �• Single, married, widowed, /
- .Color .or divorced (write the word)... Date of D 72�/ 2‘ 19.#,�.
/,�
Age 1. ... ars. 2Months Days irthplace GHQ w..C r% 'naa.
•
Cause of Death . .
Certificate was si ed by J�Gi'Yftt(SG.�n`�:...CGrt'�fl t°.. .. rtt�tf ' "A
Address �y� r+'-�1 ,,�yy KA
Place Burial (or Removal ;:w - .73%--e c >r e yt, ,, •
of is o tle held, Paler) dte p
X Date of Burial... t -1A....a.. 19.`/�/.
f body la o be temporarily held, di in spate later)
The Certificate of Death containing the above stated particulars, having been presented to 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
Nu , and on the b 's tba Tl HE BY GRANT A PER
KIT
to --"Tr%nrere--rairi•-ciearr:. rents- etee'rat0C
....
(llama) a)sr. ... ....
the... . e to hold temporarily and....• the body.
4I:a4ertat or penes,listing ebarge of corpse) (later, remove.as otherwise dispose of(state bow])
Dated.r e X 19.:i (Signed)(.... .�yu..Q,.h/c��l� �..�taet.
"' (�// dal Registrar
This Permit is au"' lent for the Removal (and Interment or Cremation) of a bod9to any part of the State (subject to local
cemetery or other nor.. :ions),anises removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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