Bayle, Gertrude t t<. Ct. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
£A- 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 CERTIFIlT OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 2 No._ Qty,�
RegistereO._...... ._ ._.._
Dist. No..rl 4P/ County e.c.i 7 uwii
Viitagr artIC ,.Yn-} .. .. .... ,- ..
/�J ...� saw�r(III elve street address)
Name of deceased per/
le, married, widowed,
Sex Color all-- vorced (write the word).i�%�� ree ..Date of ' 4 19.VE
Age .frY Year,. Li ..Months J.." Da -s Birthplace :...�,''
Cause of Death... 4
... i„r/.
"7.
Certificate was signed by IL17..
Address ,, „
lire
Place of Buria (or Removal)... r �4arGt:G tG>��iG
(If body I to poraHI CeIA„�i�1n space later) "' �v/
Cemetery.. . .,.(.,P,.4tra� Date of Burial... ...,i:V 19..I1.
(ir body Is to be temporarily 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 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
Numbe don the b s'
tot eof I EB�� �tAN] A PERMIT
- .. � ,/ . AS'S
( • ) dd sa)
the .to hold temporarily and. . the bode.
Wild ker or no lug charge of corpse) r r her�lse 1)
Dated.. 19...59 - (Signed)
.Deal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b to any part of the State (subject to local
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