Dudley, Lois t nrm VS rl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t? This Permit can be signed only by the Local Registrar (Deputy or eubregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred atter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No..
�� a.�,.
-us e... cf%�� ce./ ,l�t,V r.... •, _.....
Disc Not��Ql. County� v
t..) m(;it�r• •e*LA=���� y.glee street address)
of deceased JC�.(�J .
may, Single, married, widowed, .et .r
Sex t4• Color...aa� ...or divorced write a word w*2 O Date of eat!' 19#
Age Year• Months Day's Birthplace
Cause of Death.. •
Certificate was sign y M.D.
Address ....
Place of Burial (or Removal) taarriLl
(it body Is to be totopora eld, s ace er)Cemetery Date of Burial .'.erg �tj // 19,r',/
.
(If body I to be temporarily bed,gll space later) CC��
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SAPISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, a on the basis f I NT A PERMI
to � t . . ..
(Address)
the to hold temporaril • and... . .. .. .. .. ..... .. . . . he body.
(Under or rooe hp a charge corpse) ore,or Irwin dl to 1
Dated /1 19. .. (Signed)....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ject to local
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