Bulway, Veleda ,:el N's.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
SA' 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.
Town .
Dist. No �k'9/ Cou&,.,e,/..". ...?
Village.... ..- .j
te-
` ��^ or City (If city,give street address)
Name of deceased /,� U.. .-C.C�...
�� Smgle, married, widowed, ,,
Sex.. Color... r divorced (write the word) ��C��l'�C Date th �d 1917
Age 0 Ye, 0 Months k`,?' D ys Birthplac
Cause of Death --c--fT. - .2 Q-e*e-u ,-/► ,, - ,�
Certificate was signed by6.2.,, � �'n
Address a
Place of Burial or •emov l) . .. i
(If body is to be teior! ly held, 11 s ce ter) �y� .... ..
Cemetery to o Date of Burial ...8� :.&.<j.19.4S
(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 the basis thereo I H REBY GRANT A PERMIT
�j (Address)
the to hold ter.�porar and t body.
(U or person having charge of cor se) }�_ 1u
Dated .. ,_remove,or otherwi snoaf�,ho�I)l�
�s ..9... (Signed) / D'' :'
Local Registrar
This Permit is sufficient for the Removal_(and Interment or Cremation) a bod any part of the State (subject to local
t".-po
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