Bennett, Andrew Form vs.fi. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) 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 1N DURABLE BLACK INK.
Registered No............._.._...._...._ ..
/_ y Town
Dist. Not W.s /..Count•/ �""r Villa e..
or City (If city re street address)
Name of deceased.CnFt.9. l l .trona7v
��yy� pp� — Single, married, widowed,
Sexrfr h Coloir or divorced (write the word1i "'tP Date of Death . . . .../— ��19..rl
Aget1 ars.ad. `/ ay., rt nth D Birthplacesa nrM� . . f
Cause of Deat ,,l ...
Certificate was sin bya 4..e-�-e�-"«�a M.D.
Address. . _�^
Place of Burial (or Removal).... . . ... . ...VF'� ....fT��
(If body Is to be temporarily held.till et later) •
Cemetery ara���ae �C Date of Buria1014 Ai 19 ...
(If body is to be temporarily held. till In spec ter)
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 Ott the_ba ' t I REBY GRANT A PERM
thel ... . . . . .... .... ..... ( ,.l.Itf.c .4......to hold temporal' and (Address
the body.
(u Berta r or;eraon haying charge of corpse) I mo or otherwise dlsoose of Estate howl)
Dated Y....na 19.5c... (Signed).. . .
Local Registrar
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 carrier, in which case a Transit Permit (VS No. 62) is required.
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