Ouderkirk, David 11 P n VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
X2r 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 CERTIF}} E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK, Registered Nra. AS 0
le- 41
Dist. N Gb7 County.... ..S.. .................. (
�y/�^�/ ' ogity f city,give str address)
Name of deceased �ja{�{
������ ihM Single, ,r ieor—eed, �,.�1 '/
,A
Sex.�� 2 (Color o=- 1io-n :*a e word) .Date of ,.74 19.54
Age "") Years.. --`� Months Days Birthplace .. z
Cause of Death . . J
Certificate was signed by /¢., tG `� M.D.
Address Rt' en
Place of Burial (or Removal T ‘ 4 ,— /
(If body is to be tempji h ce late ) '/
Cemetery �,�y�T Date of Burial.... ,/, 19..T1
(If body is to be temporarily held, 11 in space later)
The Certificate of Death containing the above stated particulars, having been presented 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, the basis t ,reof IiFrREBY ANT A PERMIT /
to •N -1
the U . ) to hold temporarily and A ress) the body.
(U er or penspp having charge oLcorpse) / }°ter ve,or othvawise dis of eta ow])
Dated 1. 19... r/. (Signed) `/L/ • .. ....:.... ... .... ...L/.:.... ....
Local Registrar
This Permit i sufficient for the Removal (and Interment or Cremation) of a body to any part of the State subject to local
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