Macauley, Marylyn t..°,ni%.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tom' 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 CFRTIFIcAf OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.... 1.
T____
�f-'
Dist. No..i a.?.County... Viva r •,• 'Ya/ ,..2e �t-
rare. Q ••• (If city.give
street address)
Jam'
Name of deceased
s� Sing e, married, widowed,
Sex ✓ Col • or divorced (write the word Date Date of .. 19,
•
Age AL anths. Days Birthplaces.. aa.r W. .- .
Cause of Death •
Certificate was signed by M.D.
Address
eze
Place of Burial (or Removal)
(If body it to nbaa�ttyorarlly Id,di ace later) Y J
Cemetery... ./T �t� Date of Burial .e► r lY
(It body fa to be temporarily he .8n In apace Inter) / '�'
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
Number, don the ba •s ereot ,}�H • BY GRANT A PERMIT ��/
to (.�t/ a/6 7
adds": I
the •
• to hold temporarily a, aC� the body.
(Gild to r or person 4, bi barb ore,rpae) (I r� or w berwl 0
Dated I5 19. (Signed) • 7)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Stat (subject to local
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