Butler, Garry I.•:in 1,.GI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
it This Permit can be signed only by the Local Registrar (Deputy or subregistrar) or 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 DU LE BLACK INK. Registered
Dist. NosS40./ County Ala- Viftage a t•C-elleC .21(3)aele
Name of deceased _:A5etseclSor.00:01.4yeti of city, give street address)
hea Single ' , witieseett, ' tee, afa,V 19.,e/
Sexn Colorr" .. ......or d' • (write the word). .. .... ... Date o
Age Years., *is ay • Birthplace..:fratice. LeTai.
Cause of Death ,41. I
Certificate was signed I der^ • or .. M.D.
Address ..:;:a... .
Place of Burial (or 1 Mbra01). p ireinatep
Irettledrate.
(If body Is to be ternp
Cemetery . Date of Burial...4red‘r 1951/
(It body Is to be teo warily held, fill In 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 t same for registrati , have recorded it in my Local Record with the above stated Registered
Number, o e i er I EBY GRANT A PERMIT
to „er, AI fe
• . (Address)
the re to hold temporaril the body.
(natty korsonir ring charge of w
corpse) ( ore,or otrwl wee of te how))
Dated 19. ./ .(Signed)
Local Registrar
This Permit is sufficient for 010 Removal (and Interment or Cremation) of a body to any part of the Stet (subject to local
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