Perkins, Margaret Form VS.et NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re 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 BLACK INK. Registered No 3 6...
Icaurk-
Dist. Nod-401...County.... age, L cz— .0--G%�
�91" (If city, give street address)
Name of deceased ae ..... ... ,.
7 Single, marrie widowed, .j, �f Sex '/ ' Color ' divorced (write the word). ... .... ate of earl.d ... ....19.. 'r
Age Gv Years //. . . ....Months...... .02..9 ..Days Birthplace 4... .•.
Cause of Death .- .........1Z.
Certificate was signed by '- . . „M,D,
Address • / .12 ...1".�a .n.R,l/.IJ-
Place of Burial (or emoval) ,
(If body is to be tern ly held,fill in space later
Cemetery ..lLn� _ Date of Burial.. ,.2e-1.., ../k l
(If body is to be temporarily held, fill in ce late )
The Certificate of Death con ining 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 acce ted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbs , on the asi ereof I HEREBY GRANT A PERMIT 4�
to ,
am ddress)
the .. .. to hold temporar' and t e body.
(Un r or person yyving charge corpse) mo , rwi di pge of[state ho ])
Dated.. .. . 19.W. (Signed)..N. ‘..
ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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