Lyle, Emma Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT -
gar 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 occurr after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFI OF
DEATH, LEGIBLY WRITTEN IN DUR BLACK INK. Registered No.
ry Dist. No•,.) �I...County .. e , Z°
A Or ty (If city, give street address)
Name of dece ed /��j� cL �r
Sex��Colof��"'u ofr�ritelthe word .wed, ���f `� Date of each „ix/ �� 19.7
Age ,2I Years �1� G Days Birthplace
C•:use of Death
Certificate was signed by.... .. .... ..t. ... .. (., M.D.
Address —'�"r'�J.. fes....
'i '+y..
Place of Burial (or Rer'oval) '% -
(If body is to be temporari `,,- d, fi e I r P )
Cemetery 46. Date of Burial 2.--7 19. 4 L'
(If body is to be to ,•o !lily held,fill i space later)
The Certificate of Death co aining 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 e same for 'strati , have recorded it in my Local o with �ve stated Registered
Number, n the.basi a f I EBY GRANT A PERMIT
to
the to hold temporarily and.. the body.
(Undert er or pe o avipg charg corpse) to o pi.aktd.eress)
r othy is s o to bow])
ated �� 4 4 19.Yt (Signed) e
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the St a (subject to local
etery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 6 ) is required.
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