La Mora, George t-:m Vs. Cl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
It This Permit can be sieved 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 CERTIFI AT •OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No,....
Town
Dist. Nofib/ County a4--' - Village d` hrii..," .. .
A/ �j or City • (If city,alt..piMet address)
Name of deceased AL �0` /` 7.ap5 " - C
�- / gle, married widowed, . �j
Sex. Color �/ ..r divorced (w�`fte the word).eftk ort- �tr.G® Date of Death el I9J`�(..
Age tt/ Years V nths../..Zd Day irthplace ,
-Cause af.De'td. Ear•^ .'�1• .. .. ...:. •
Certificate was signed by .Ifrtn,..+....n-, i- M.D.
Address
Place of Burial (or Removal) ,..G. "- '�-'g-rrr..
,9
met 4 to be temporarily a fill ee r)
C
Cemetery .. Date of Buria f 19 Y{....
(If body Is to be tempos Ily held.011 pap later)
The Certificate of Death con aining 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
Number, and on the bag' thereo I EREBY GRANT A PERMIT ,.,�� /e
to.oll�f :fw.dl._ro1r! _Ag.. - - , �.tt/���•� I-./
the.... e4;ut w /
to hold temporaril n ., " '' I e body.
(Lode ker o arson having Nmrge of corpse) (I e,or other align.�r'
y� a /
Dated ��'. 1997 (Signed) [ ... I /% /�
Thi ermit ' sufficien'f for the Removal (and'Interment or Cremation) of a body to any part of the State (sub''ct to local
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