Rowe, Nellie I r,n VS. al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 CERTITTE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Register O. No.....
-
Dist. No... .�. County �rVillage... .? `J ..
} ' (If city,give street address)
Name of deceased4. �.. r . ..
Single, married, widowed, v� / /� • ,/
Sex �.y` .dolor . - m d (write he word C... Q���% Date of th.. ..7....19.T
Age ! Y s Months fa .Days 1: hplace.... •
Cause of Death- ... ... .. .. . -^...,./ •
Certificate was signed by M.D.
Address
Place of Burial r Removal)....
(If body is to b orarily held,fill in Space later)
Cemetery... . ..f .. Date of Burial .. .. .. . ../e...19../.
(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 registra ' have recorded it in my Local Record with the above stated Registered
Number, and,.n the basis t ebb A A PERMIT` G� A,
� e) Address)
/the IAA A. s� . o / to hold temporar' nd ..the body.
( e or 'erson .,v barge orpse) r, ,or otLltlTvise dish state howl)
Dated .19`, .sr (Signed) t
ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod to any part of the State (subject to local
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