Smith, Powell `
orm vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rir 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._.Z-/
Town �L
Dist. No„aa0./..,.County ilktge I/. ,..
ff—C-2,-/ze
(If city,give street address)
Name of deceased •
Single, married, widowed,
Sex...d ,......Colorkoo��/.,. .or divorced (write the word) CrA
. Date of Deat /C? 19.`,r
Age 6 7 Years Months DayErz--• Birthplace.... „e„�A,.r'd r2... • ••. 42•••2I•..,
Cause of Death.. ,. ., .. — - .
Certificate was signed by M.D.
Address 2 -t•
Place of Burial (or Re.�. al)
(If body is to be tempora . d,fill,in spat )
Cemetery ..rtllLQi ..�:�.tdi`, Date of Burial /A••••19•
(If body is to be tempor. ily held, till 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 acce.ted the same for regis tion, have recorded it in my Local Record with the �bpv?e�stta/tted Registered
Number, ' on the b:r is� ' -3(...
A PERMIT ���
the ..0(A ' '. to hold temporal' a �i e body.
taker or person suing charge o Tse) (In , ov other ' so o rata ,r" 7
Dated„ �....._/,. 19._ -�\ (Signed) .... . '
Local Registrar
This Fermi is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s•.ject 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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