Overocker, Emma Form VS.at. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gs 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 D BLACK�� , INK. Re ' tered No.._..-__._. _._._
T
o // ) .. .. . . ...�' Village .. , ��
Dist. wn
N . ..CP.��.Count • ..... �,��� ��G..��>;,f.'rCi.Cc lf—��- "�...
pp Or Crt (If city,give street address)
Name of deceased . r1r— fCC 4�
�/ Single, married, widowed, •
Sex Color..,./ or divorced (write the word)..�f.'Y(lf%YI-e-P�Date of
D � 19h`...
Age. . 77 Years 4onth J/f Days 'Birthplace ../4• ,,../7a.Cause of Death . .rtra.x.kI--2-944y.e
Certificate was signed by l,‘re, . M .r�r a M.D.
Address , 22 3..2.�i:e 7.e. --Ise-"—
Place of Burial (orRemoval '� df fr ���
(If body Is to be temporarily hel . I I �ces 7,444 _ / /5
CemeteryDate of Burial .... .��. . 10.4
(If body la to be temporarily held. ell le 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 Record with the above stated Registered
Number, and on th itsis GRANT A PERMIT tobiAry _ ?
Jy
gIHEREBYthe To.... . .(x .. hold tem ,r!�7 poraril nd - £.t>teddress) the body.
(Un er1E person having charge of corpse) r, or othy�e*l*dtenose (state howl)
Dated ....71(!,...../.�f 19.4!,/.. (Signed) .A
Local Reglstrt
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common canter, in which case a Transit Permit (VS No. 62) is required.
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