Brown, Bettina f a•J /
Yens Va.ei. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir This Permit can be signed only by the Local Registrar (Deputy or subregistrer) of the Primary Registration District (Town,
Wiese, 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.
T'err11�
Dist. No /O ' Count
`I p atr«t add
Name of deceased...Aeat":("tc.",,,,Z-n-ca 'or ��v]'c q. -�' c�kc�l
. �Stngle, married, widowed, C/ e
A Co1Qr,. or divorced (write the word)+ Date of Dea `S' /^...19 `i.
YearsMona-P�' Asys Birthplace `��^e-'L ... ?F4rft%+rf
Cause of Death �/" r-
Certificate was signed by '�� 2n t M.D.
Address
Place of Burial (or Remov , .:�' .:......
(If body la to be temporarily bee .}"lets es later) s.
Cemetery Vr ""t" & e f - "' Cy- - -4-J Date of Butial..s/�-` ,, 19.5?..!
(It body la to be temporarily held,fill In apace 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 RegisteredNumber, an e ° th 75 I EREBY GRANT A PERMIT cze `
(Name) 4, —C C (Address)
the to hold temporarily and the body.
ma r parson baring charge ofcorpse) (Inter,remegeyor othevtie disown of(state how])
Dated t� 1 19.. / (Signed) Yu-�1- rT.,- /,.?..-;2—�• Q"'� �yy
Local Registrar en . C? •J'-,
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 rerrsoodl L by Common carrier, in which case a Transit Permit (V$ No. 62) is required.
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