Blackmer, Ethel •
Farm ig.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT •
sr This Permit can be signed only by the Local Registrar (Deputy or subregitftwr) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFNE OF
DEATH, LEGIBLY WRITTEN IN D RABLE BLACK INK. Registered No...,2".... __—
Dist. No....i.Z.0./..County.. .. ...(Zeteistorre•---
Ae‘
.....D4w.u—
minage
• et — a.. .y
6.1 tY (If city. give street address)
Name of deceased
married, widowed,
Sex.S4Color;lisatr )r divorced (write the3tord). • . . . .. ate of e th.. . . .,...f 19.friei
Age 4.7.3 Years Months of r Days Birthplac
_ .
Cause of Death... . ...ite.4-002.94-1-Ineesied
. —44,42aS.421:444(es
Certificate was signed by . e
MD.
Address ./17
Place of Burial rrR.71:51120Val). pace is )
(If body Is to Do aHI eld,
Cemetery... V.. Date of at —,taar- ,,,, 19.1,
(If body Is to De temporarily ba).MI 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 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, on the dm ' th f I REBY GRANT A PERMIT ," , ,
to #. ai ...Yet:La.-- ...
.. ., •
the to hold temporarily nd (Address)
• ..... Ar• . ap the body.
rtaker or perso h sr ng charge oit corpse) • or • •ervelse 4 • Jr' .•
"iv.7 / at .1 -1-
])
Dated.. de 19...y.t (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
. .. .
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