Lewis, Nellie Form VS.GL 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 SLACK INK. Registered No. ,�.. ......
Taval
Dist. No...%1, o Q F County q age y 7 ,,, „% :lei.-'
C� p�� ii-r-C -te-WA-‘,122i
(If its, gi.e street address)
Name of deceased f:C.��.C%G.G-(— ...fib / Single, married, widowed,
Sex t. • Colon` ' or divorced (write the word j Date of Deat ...t.7....L4.. . 19.1 ,
Age 1e Years '`, .. ... ..?11 nths -- Days Birthplace CZ.,-,.....gr.... ..7 i• .,
Cause of Death..a.t. 4
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
(If body is to be temp rill d,fill in space Iat.r)
Cemetery Date of B rial kY • al 19.,."
(If body Is to be temporarily d. fill in space later)
The Certificate of Dea 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, -.A on the basis there° HER Y GRANT A PERMIT
to
er 60.Kett i. c.ttleZ? • 717.
'au (Address)
the .,to hold tempor and the body.
(Uncterta r_pe on evi charge Vrpse) ter,remove,or erwis a of !tat owl)Dated r,G� :wef 19.,,t (Signed)
Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body t any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier. in which case a Tra sit Permit (VS Ne. 62) is renuired.
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