Hill, Eber Form VS.St. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sa• This Permit can be signed only by the Local Registrar (Deputy or subreenar) of the Primary Registration District (Ton.
Village, or City) in which the death occurred after the FILING and acceptance d a CORRECT AND COMPLETE CERTIFICATE
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. RegistZ........:
Town
Dist. No..s.512.0.kountym•0ip Vil 921"}210-rsicee
• o 1 (Ifcity,city,give street address)
Name of deceased ' Cr- —W '
Single, married, widowed, 1.---12, „ ..0 _
Sex. .. .Color.a....or divorced write the word) /v"-/K-11"c4K -e*Date of Death..8“ - 2.6 isiAli
Vzi.
Y s /0 Days Birthplace
Cause of DGth e
Certificate was signed by • ee, • - M.D.
Address .. ....%.7.12..,.9tra,.. .
Place of Burial (or Removal) Shit
(If bod 1st be Ily held fill In ace
Cemet....... Date of Burial / 19..g.,
(If body Is to be temporarily held.fill In space later)
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 S TISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registrar, have recorded it in my Ae- Record wit) the above dated Registered
Nutdonfliss.,z5 I 'RE GRANT A PERM
to do. alle.
, ( tithe's)
the to hold tempor • and the lzy.
(en r r person having charge of corpse) •r,re , therwiscns2Zell
Dated • _2 7.19. 441 (Signed)
Loral Registrar
This Permit is cient fir the Removal (and Interment or Crem 1 ) f a bad o any part of the State (subject to local
cemetery or other re tions),unless removal is by common carrier, in whit case a nsit Permit (VS No. 62) is required.
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