Stafford, Thomas -• NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
\ar 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 URABLE BLACK INK. R�' /�NQo.
'ff Town �, 2r 'Gl
Dist. N "1..� County....ea/ Villag ... Y Y:'''
,—.." —er-e city,give st t address)
Name of deceased
� Single, married, widow i �7
Sex...�',l f.:. olor.... .... .a o divorced (write h or ate . .Lr pC 4 19..
. .. . . ...... ..
Age Years. . Months D
Brthplac ... r.. ..1�,
Cause of Death .. „ „
Certificate was signed by... �. M.D.
L�"
Address / ! / /2
Place of Burial (or R oval) .�hCn2.... .. .. .... ... .i• c
(If body is to be tempo r eld, c at I/ 1
Cemetery �.., 4/�L, Date of Burial.. •,9 d 19`7
(If body 1s to l e tempo rily held,fill in sp e later)
The Certificate of Death contain g the above stated particulars, having been presented o me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hav accepted the same fo registration, have recorded it in my Local Record with th above stated Regi tered
Nu r, and on he. asi ereo EREBY GRANT A PERMIT h
to... ' envA /! .
ame) Address)
v to hold tempor rily n ...the body.
a••erta er or pen 1 ing charge rpse) ter,remove,or th a dispose of to ])
Date. ' 4....I 19., / (Signed) .. .. .. ... .. . ...
ocal Registrar
This P .. it is sufficient for the Removal (and Interment or Cremation) of a ody any part of the State (subj ct
cemetery or other regulations),unless removal is by common carrier,in which case a Tr nsit Permit (VS No. 62) is re
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