Patterson, Mary Form VS.St NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 DURABLE URABLE BLACK INK. C Registered No. 4,0
TtrWrI
Dist. NoS60/ County lN. .... e..jiZ�!-l� / dr�J •
. r (If city, give street pfldress)
Name of deceased .f
Single, married, idowed, '
Sexi .. ...Color.. .`!/ or divorced (write the word) eta�t� Date of D at . 4-- Z/ .1 r./..
Age. O Years Z Mo
nths..Qnths.... ..,3 Days Birthplaco`��� �ta.GP4�
Cause of Death '
Certificate was signed b - 1 - M.D.
Address ��i23�.�... . ..,, ' anti
Place of Burial (or Re oval) ',
(If body is to be tem r held,fivace
Cemetery Date of Burial g‘-'4Z. 19..0,/
(If body is to a temporarily held,fill in space later)
The Certificate of Death containing 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, don the
HEREBY GRANT A PERMI
to . . . . . .... .. .. .
/�� Name) � ' (Address)
the......'.//.. . . . .. a to hold temporaril a d the body.
(Un er o e n ng chargeyf�yrpse) (In ,r ,o wise dis ose of[state how])
Dated 19.�,.1. (Signed).. . -
al R strar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations).unless removal is by common carrier. in which eete a Transit Permit (VS Nn_ R21 is rpnuirprl_
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