Rinsburg, Max Form t-s. ,:,. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tY This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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 Jar
Dist. No. 74(..County.... isk.fir df�.Zw,.r Village a iit:vitims.. .Y�
�/ -(W-Gity. (It city.give street addtw)
Name of deceased ram'
l , widow ) / _ ,
Sex.... h. �Qtor... or ivorced (write the ord ..... ..,tRaftr Date of Death.. et/ 19y�
Age ,2.LYears. Z... Ionths. .l Day Birthplace
Cause of Death /„�, y
Certificate was signed by / ,,,, _ _,—...„ M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily hal fill In s later)
Cemetery � pa Date of B rial /tene?.��' o 19,y/
tit nods is to be temporarlly oe d, all in apace Uteri
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, and on the basis ef.I HEREBY GRANT A PERMIT
to :kwr44.;: -ty.
the...r ! � IFf�fl� - to hold temporarily and.. m ) the body.
tosaertsts or persons coarses�gqtt rpae) ,or otherwise dl gate bowl)
Dated y oG 197 (Signed) . .. . .
Local Registrar
This Permit (a sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal U by common carrier, in which case a Transit Permit (VS No. 62) is required.
r•-It 51 ° '' a" 5.5 'y� .lnc ^ o,ER :°.°,Ps rs'^ pR' �•.wi n .1.2 gq5.e3 ;3-E pr.i fn 3•. C
''j,n ^ZAL ?.p w s-. eZwnAG gn.. 00 ^s Dn Dt^ -oc' • tel
• >3 � n3n � .. n $ ED'aP.F3:a.Y^..n^:?..;;am ..=". , n 3.E. -- G'ao-w'n$ n 34v� 'C 7Cm v`1 • Z
-Z: 1 r._3,<^ =sayen _.=uw= o.- n _n nGu v ^ pp ;...on ^ y£ to s • o $ • O
> n ^ , om-•g= �_$�sowX'-�"L' 3 -_�oo° rwr.-di_: o•- oFz + o
n +T+��• m • ^ �Y <.NOO; �•• O _.'nr nn n ^�.n ^to S...n_ CO3n00_�• � + .^. = = = CY •N ?a.�JO - . O
t7-.x E.o Xn22 5.'oa wr: u33o •wn rN« ° �+ � - '<. n°'o o'^< uL5 R1 °•�.y.�o
P • >M" 3 .. 2n3.J'.2nr i�=w3 -., •3'0eeov^ �......: SSC3 < = ' X = . 'VAC S1, .
700Z ^ .3•-en:^:E.5a.-g2 + ..,� =c ANC.1 � , ^e= 4n.sN.uG$� ac5Z ;.0tnK^s z3
▪ I- 40 Z `< ^c np, = n n Z••1P. ^^ • 74333x333x ^ ^�0n X^ ''Q, [2.r* _.3..n `' Cr C�tn,•• 3Z
e y• e n.om.° no., G^ev 0E.,.^ n4 .-.-^ " ST a< c ^-•- Y = s0 e•�+ ° .". , iz^„
+e av °' l o.c ,^Xqq ^ -,s :?•. Ec3.Sa. .w_3 °=. E ^ a,� �._.- aY = � ,�, T3 >oe �^1
a yeC i ,•• ' Gw Gp O,= n O•- nn. -c = ON ^a O0 w fin :S12- uS cm 1:38 1 j A
• = zm S 'ru'r". I. o•_c`' = Z °'SO'o., Ma. s^ ' nG w ^rni'. 8c " t Oc0• 5 zj ' '4°
�.0.4W o.Gw nE '6o.n R8 -o''Z ^3.^_.o• v5- &-, n ST-' 3 ^C�r'-s^y,G.°. -- ".o'go, 5i m Otn
c -14-1 ,nwo + s? on3n^." .' is = ' Yn tiro,°7. a=." cw ^ 3 .^^. =.•Re °.• We + -i .�
s' x 6s' r3 ,o ^0 = ,=. - nE oo Egg" En ^nn5^ "Er. ^o , Xi , >• c yZR7
G zD 3:. s- G 'A = --' wH � ,, - • •
o n.� ° vG> '^ ^oG. 3 : _ "o nD°''o ..j X
• tOO �w 3,z'R , s'E-0 " n3 -. -no -so' ^2 o.Gn. s'< ^ nonoo_ Bm ; E ^ 3' 3 <^1
n n G C n
-
.Pw + n ^en ° 3.n %'n A° = Gcn ^ 6e -= -dc _.°"".2 9. ns P - QP. X0
e xr�f•N .n.y p <- o o o n n �^ ss G� 5.° =.J04n04° '-. 51 ;r, r- 31,?S,."... wniii < r6 ^ .- Z^Z
• .., o. '3._cn ca3.u °^ '...w Cc3- , o .n = u =`< S:ov"ys� f3 -.Nn �+ .s. t•'1 v0. �. (no
E ='wXO
o <_.a°' NoX = 30 •'+,�° ^5•,g as Ec.X c�"• �$ g.u� ' awaa��> . =:-loa 3 Y 70
s' t▪ ox5 s5•a..7,m• ' g -• •-•7c a nnE.eb $• � ^<'e 'o' G'^"" Oa.ac k � � I „�'iB : o^ h'I Z.Q
zz- s^ SSX • w ..^ =,e oo2X . < £ gX ^ c^ -S•s G= =o'<R41o ^ •4 •oils' > .]!*.
IN rnO'a= �=n , n�.�; ^� C6Y = 6 < .•C • w �,T+ e' `� 0 RI
p R'�• n F -' '..7 0 w• n z.,9.° n ^O'O N.--g." a gl --"o :"--E1-S 3.n;C > G z° •• • - a,c N
3 <i ^ &'E = ^ 3 w$ ^ •'o3 / - 8"g Sto F.Tnay. 3.^ k3 °'E ^^ -1 ..'a£ atH -03'• R 030
"o'n C+ non do,a - r x�• ' ne. o �.r= »•3"n ^ =N " o.= sE 'n cf__.G� k▪ n �' � i -1; 3.� .. R7 t+7Z
O^ -. wn ^^=0ok�3.Go =_•'^ = OOO.w R ° C.n _^. n3N .. ,< - ^oGw H.� F6'n , Z...
Srr-- n. noon ,, ^' ^'_ = G?.-.° o,..,n , o .. o,= n < n?^£ ' w ▪ Gnnn • .-I...i^, yZ
: 6D�p• W-ri =•a= ' sn `w"$.� ^T, mo5•^,'.ko H3c ^.Pt ^w ° Xi ragE r end On
;.Wit/+° n n'-^^.� o$ aG+ 3 nZ. yyew -,' nu wn u5•et^ =4 cG31C.o o2." a zo X7D
n �zr o.7� wE &E- n = o$X$45''R .o •-Gw3 ^ .,', = -° n ^ 9.• -1.^�'yw.
"`.9e - nn 50P 6Us =_J � 3 r:£`=Co = Gar. Dc5,zoo R 4no -n'Z=''060 =� tr. CMr g ni
: e £ Lv9, 'g ti o . .'< 3 o ^q' sS.6T+ 3.SM i3 ' yccnc.ort.e , 98/ •t'�•zp m
ne 7m7pi .:..°:.4 _'w7=n • ^ 3 �i"=:-^.5. °'GEc:o na'o9 -c ^ T_.< ^t .. t� O
41*1„ o^wA �i nA • o�36,< -° nw:^. =now ��°. a=oa34w 4. 52,. la^� � A 't7