Shappy Jr, John .orm VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lAr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. .e2//
Town ��
Dist. No... : a County �.�.'�L'G�,C2.?11.2! Village /34/ �Q,u .a..'eq..f six t..c?a,/-4..c
O Clty (If"ty,give street ad re66) 0
Name of deceased , �r�" �•••�
�,l� Ingle, married, widowe ,
Sex % 2&Color.� 4 or divorced (write the word)... .. ... .. .... ate ofDea h.., . . . ...c. 19.!f�2.
Age yQ Years Months /fi...Days Birthplace g . .. . ... .. ., 4;.
Cause of Death... .4. /ea ...,,.....C4.4-rx .._ U. c dc4 ./0.. i,�
Certificate was signed by.......... .....al• . . 1,
Address /7/ 4 ....., lS �-(.e� ."araser,....
Place of Burial (or Removal) 9Gt-r.fi7ze./.... .. _....QK Ge ?.:4-e,4 ,4
(If body is to be temporarily held, fill in space later) v
Cemetery �Q�Y Date of Burial s? 19.. +g
(If body is to be temporarily he d, 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 the basis the f I H REBY GRANT A PERMIT
(N me) (Address)
the to hold temporarily . / / the body.
(Undert ker or person aving charge of corpse) r ve or otherp e d y•.e •r Aor ��,(e how])
Dated a •�i 19.... (Signed) Ggi •ar
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Stat• (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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