Bayle, Myra Form VS. Cl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
N This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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 DURv/fBLE BLACK INK. Registered No
Town /,
Dist. Nora.G..Q/..County...................✓....C.<..::.::; ..Gs.:crk. Village T (e 5Art L --- e.
(y'. ij Or City / (IC city,give street address)
Name of deceased `t-0.' .7� I (�'C
'n e, roamed, widowed, r
Sex. 1 r. . .. ivorced (writ a word).. ate o th..... .... . • .a2..'Ca�...19.. . •.
Ag 1f�ars Months D ys Bi hplace... �
Cause of Death v. . .. �.Qf1..a. .
Certificate was by • li '�-«4a, r .. dlfl— ,,M.D.Q
Address . . ... .. .. C `(�fei
Place of Burial (or Removal).. 751Jtr�' .
(If body Is to be rarh held,d111 pap later p'• , j
Cemetery ' �CV Date of Buti al.Q 19.4.4..-
(Ir body Is to be temporarily held.all In space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami45
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, t
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis eof I HEREBY GRANT A PERMIT A.�i G
20 r.''�//i-'f,9^ ...LL.r....W 1 . V" . ' .. ... . i rs .te
t-sd C.t e
the .Lus .. (. /C -'I to hold temporarily and (Address) 7 the body.
( N onpe a�yt cher¢f yt yorpss) (toter, ore,o/.wr�dee/ vole for Ia to how))
Dated . .::ct 7 19.1.{ F (Signed) y t l� y/l(�e 4` G� f,
r.. •••. .•. V' Local Registrar
This Permit is sufficient for th.- R•-moval '
(and
Interment or er. m vitae f a tons any part of the State (subject i local
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