Cheyne, Louisa Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ur 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 CERTIFIC 4./4
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. �L .7
Tewir
Dist. No....-0.a/ County ,„,1 Village.. �' *
or-City (If city, give street address)
Name of deceased
• �-�S I•ngle, married, widowed,
Sex.. . or. �� divorced (write the word). ..cam r`"Date of each. r..19/
Age.... 7 Ye rs 3 Months 4=7...3 Days Birthplace.... >7•,
Cause of Death . . .. . ' Z .ae.:d 1�4.4,e.�,t �`��-�� �! , ,,,...,,,,y1_
rer
Certificate was signed by , 2 M.D.
Address , �j�.:•.•y... . '� •
Place of Burial (o •emoval) "i n ••C_.Q.4.
(If body is to be te„.o : ily held,fil;p7f)ace later) �]
Cemetery ,,,e. Date of Burial.�� . A/ 19...W
(If body is to be 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 basi her I EREBY GRANT A PERMI
to C. ---alat ,"V.
Na (Address)
the to hold teniporar• and.... the body.
( tak r perl ny�ing charge of corpse) n er, r rwise sgos fate how])
Dated... ,, l�-Llk� 19.'t.7... (Signed) .
Local Registrar
This Permit is sufficient for the Removal_(and Interment or emati ) of a ody to any part of the State (subject to local
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