Boillargrou, Herman NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Lr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) or toe 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 D RABLE BLACK INK. Resist No..L..y�.A:—..—
Town
Dist. No..�l�.- .0/County • .... .�GZ/7/G,Q.C.1 ' lage... ra. / . ...
I/ �/ ity (It city,give st address)
Name off�deceased '/yet'.-�/�i•�C',�I?`t�?r4.C.SGeGdd,.. . ..
%Oa%a-CQC Ingle, married, widowed,
Sex.. .../ Dior. divorced (wr'te th word).. Date of h� 1
Age..::/ Y s f Months ...../6 Da Birthplace .. . .. . . . �. .
Cause of Death.... . . V .. YC
Certificate was signed b rC./ M.D.
Address � dQ,�„ • y
Place of Burial /.r Removal)....s .. .. . /! ' ..
(If body Is to be •• be! I v I r) {/�•
Cemetery.... SII�...-...... Date of Burial // -19 4.1
(It body I to •• tern•orarlly held, Oil I vace later)
The Certificate of Death containing the above stated particulars, having been presented to e, after careful exami-
nation, the same appearin to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have epted the same r regi ion, have recorded it in my Local Record with above stated Registered
Num , and on di a her EREBY GRANT A PERMI
to ( - a ,
the to hold temper r' and th odv.
(e.`aa9re r or person bar charge o corpse) r r m ve.or ere o0 to bowj)
Dated......./.../.L. ti01 19.. .f (Signed) t�Gr.
Local Registrar
This Permit is s fficient for the Removal (and Interment or Cr a on o a to any part of the State (subject to local
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