Jarvis, John Form vs. 41. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr 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 IiRABLE BLACK INK.
Re ' fetez.d No.._.._
'JJA� IlLL Town
Dist. No eS ':17Cou Village.: t --fria y
oLClty- (If city,give street address)
Name of deceased
widowed,
�.y) �/� Single, ma� / /L2"a
Sex 7 ( !f....C_olor..... r divorced'(writ he word)... ..: .. . ate of r - ,. ..:...e v 1 .:( t
Age 7Q,C Yeasty. .Months........ .. .. .Days Bi plac .I e'. 7�/n r" `
Cause of Death // .. ... ..L.:..,r,# In-t..r..rr.C,.
Certificate was signed by! a -cam M.D.
Address lwL-ld. , ..— •Place of Burial (9r Iikmoval ., •.e ---.57..E j .ZI.Gr4..c.......' t -a!
(If body Is to be temgondty bald, (pala r/ /�
Cemetery ui" � Date of Bun ,4,,.L.L.r ! 19. /(If body is to be tempo(arily held,ill Inkter)
The Certificate of Death contai the above stated particulars, having been resented 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"Reed d withthe abov stated Registered
Nu and on , sisAbereop HER BX GRANT A PERMIT% a 1p
_ (Name) (Address
the `� to hold tempor rily d. I// the body.
( dertater or pereon etro ebarge o corpse) ter,remove,or otjterwl pose o2 to bey_-
Dated . ... ....f..... 19... &J (Signed)/.. -),.�
( •• •. iL,.•. ..Local Registrar•.
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which ease a Transit Permit (VS No. 62) is required.
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