Bennett, Leon NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can be signed only by the Local Registrar (Deputy or eubregistrar) 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. y
Teen /I�� ��p� Registered No�l.�-.
Dist. No.7tie.Q./ County ..cV11t.Evv Village L.4��Yy
.. Or City/-y� ur city,sire.tree caress)
Name of deceased ... .. . .. �ri GllA/V J
`�,,,, y,` f Single, married, 'dowel,
Sex.t.l.(d(. (....Colol'K��[ or divorced (write the word). 1 . . Date of Death... 1.r. ....19..{12.
Age of 7 Y ars 2- Months; ll s ,/, Bi ace... 71
Cause of Death. . . . . Janet'.... , /. . .. . . . . . . .. . . . . . s7. 1.
Certificate was s greed by r....:) M.D.
Address.
•
Place of Burial (or Removal) tLl. c'1 �! ,
(If body Is to be temperer! ell,en in epees q N
Cemetery..`wtet .:,./Y tiro Leta( C2n��� Date of Burial...l ail .2.2., 19J2
(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 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 a basis-thereof I HEREBY GRANT A PERMIT
(Name) (Address)
the to hold temporaril d the body.
(Uqdertakw or person haring charge qr corpse) .(/ (In , erwise dlsooes of(stab bowl)
Dated.... t.C.. ,Z.2, 19...1.C/... (Signed).. �r�
La Registrar
This Permit is 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 mimed is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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