Smith, Frank Form VS.Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr This Permit tan be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Dist ' (Ton.
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERT P
DEATH, LEGIBLY WRITTEN IN DU BLACK INK. ✓C/,/
/ (/ Regis No
4.
Dist. N :a ...County. ... ..fa y 9 7F �
��J • (If city, e street address)
Name of c eceased . �«" ��r'/r/ /., a �y _
�Ste C. married, wiefotped, 7/60e to /` il-...
S Colo, c.. diees ed Kits the word) Date of D ath p 2 19�/
Age...... ....y Year .. .7 \fonts felt Days Birt place. ./6 int 4t-Y�S,— 11..,r..
Cause of Death t / . ��
Certificate was signed by.:. :.. ��� H.D.
Address
Place of Burial (or Removal) a"^)" ... .
aliti
al body Is to be tern y he On In apace later) it_ _
Cemetery / .. .... Date of Burial..... .... .. ...........a 19 W
Ur body is to be temporarily held, all in space later)
The Certificate of Death containing the above st ted particulars, having been presented to me, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have acce the same f r regis ion, have recorded it in my Local Recor with•the ve stated Registered
Number, nth sis her REBY GRANT A PERMI
the to hold temporarily (Adamsthe body.
( to er err on having chargept corpse) ore.or otrwI w f state bow])
Dated /.(!fit�J" 19.T..1.. (Signed) ( r. ..Yr %. sir
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the • to (subject to loyal
cemetery or other regulations),unless removal 6 by common carrier, in which case a Transit Permit (VS No 62) is required.
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