Odell, Harriett Form VS.81. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gm- 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. R gistered No.
,-/
Dist. Noc-j fo Li(County JII)c?--4-4,-e4-1.,,, Villar
If city,give street a dress)
Name of deceased Wie,d1 tiGz2ZA..,f--e:PCitY ' afe-11
)Sex. €4.14olor—L .1/.11 Single, married, widowed, ('
or divorced (write the word Date of Death
Age / Years 0 Months ;RS- Daysg_ Birthplace..
Cause .
Cause of Death e,,‘ ,..,,,d,, . .174 .. aw,tvg-rir-.r. ' 7
Certificate was signed by A. 474 i • M.D.
Address
Place of Burial (or Remo al)
(If body is to be temporarily he ,fill in space later) ;;4 17 at-
Cemetery ,. . Date of Buria1741-1r-c--1 i 19.XL
(If body is to be temporarily held,fill in spac er)
The Certificate of Death containi 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 Registered
Numberi
to rIcz,c, a the ,
o - ClItANT A PERMIT
•.--.` t \-,:: ./i.V
if oe*
Z, a ) r ress)
the :-. 64.4 4.OLletl'artet i to hold temporaril the body.
cilh,ldraker or prksonlWarge of corpse) In r,r o , r ot wise dispose of[state how])
Dated.., .444C-14, 19. P. (Signed) t..
Local Registrar
This Permit is sufficient for the Removal (and Interment or C; a t a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, n whi case a Transit Permit (VS No. 62) is required.
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