Adams, Georgia I •:rn A's.SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ct This Permit can be signed only by the Local Registrar (Deputy or subregistrar) oi the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIEICiT F
DEATH, LEGIBLY WRITTEN IN DU' • ; BLACK INK.
Town
Dist. Noaa./. .County.. arfi- illage
, ity (IT i. glsestree addre )
Afe:// .0 a" ...
S4,4
Name of deceased
/
Singli married, widowed,
or di%orced (write the word) Date of "bath As( 19.p
Age p Years Mon s # Da s • hplace if' .1 71144:44-4..
Cause of Death detcot • .Z./AZ.4•CA
Certificate was signed by. • .. M.D.
Address
Place of Burial (or emoval), . If-r
(If body Is to be temp Agri pa ater
Cemetery . Date of Burial Ar 195.(/
of body is to be temporarily held, till In space later)
The Certificate of Death containing the above stated D rticulars, having been presente o me, after careful exami-
nation, the same appearingto be COMPLETE, CORRECT, AND SATISFACTORY S REQUIRED BY LAW,
I have ace ted the same or registr ' n, have recorded it in my Local Recordwith abo tedIatered
Number on $' tWof E Y GRANT A PERMIT
to r - 1 2.-f
• •
the a to hold temporarily • oroth Bey
he body.
Made (It or pereonng{thornJO corpse) te te e I dis
Dated . 19.9C/ (Signed) C.- t
Local Regisifar
This Permit i ufficisnt for the Removal (and Interment or Cremation) of a body to any part of the State ( bject to local
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