Hall, John Form Vs.6i. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
te 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
Town
Dist. No✓�.... ...`.......County....� Village.
A OFf (If city, give street address)
Name of deceased �v�• ,/Z.f...G��r
, �� � - Single, married, widowed,
Sex14't o1or.�.�l .or divorced (write the word)'. Date of Death. 19.5,--/
Age la.../' Years Months y,r Days Birthplace
Cause of Death................. ... ... .... --Leree "14-exe:Z .0
Certificate was sign
y... (- M.D.
Address --' �y`G ,.. 1 �- '�
Place of Burial (or Removal) ~ ?..
(If body is to be temporarily held,fill in space later)
Cemetery Date of Burial.. .i �''.. f�� 0 19.*.
(If 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 be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Recor with the above stated Registered
Number, and on the basi9jaereof 1, HER Y GRANT A PERMIT-
to
.."--7-4.'
�Na�e) ddrea )
the ��t,/ to •
hold temporarily d . . . . . . the body.
(U ertaker or person having charge of corpse) (I ,r or otherwise dispose of[eta w])
Dated.. .l. Gr"• .--c7 19 ill (Signed)
ocal Registrar
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 removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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