Baril, Emma = », I GI. NEW YORK STATE DEPARTMENT OF I-IEALTI-x
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 CERTIFICATE OF
DEATH, L,E//GIIBLY /WRITTEN 1N RAVE B;. CK INK egistered o.
Dist. No`f� ,�Y-Count Villa y/7 y
... ... . r . Village. ... .. .. .. ..-. ... . ,
Or it FI ty, give st'eet ad ess)
•
Name of deceased.. ... .. '
Single, marri•' , widowed, �{ (/
Sex...... ...1 Color.. ... • r,.r divorc�_<1 (write the word .. Date of U t q 7Z-
Age /AS Ye. ., Months - ....bays "plthplace ..
Cause of Death / - _ .. .
Certificate was signed by....... •,I D
Address 46' ,► �" ,..lor 111: '
Place of Burial (or Re v ) i / „i or(If body is to be temporarily e 11 . •i /
Cemetery ( ! ae-,-�J.l Date of Burial c. v(. ,1/ 19 )LL
(If body 1s to be temporarily eld, fill in space ter)
The Certificate of Death containin_• 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 gistration, have recorded it in my Local ecord wit the above s d Registered
Nu and on sis t eon H Y`GRANT A PERMIT ____&/' '
l/--- (Name) �— (Address)
the to hold tempor ily ... e body.
DateT rtaker r pets havi g harge goo se) remove, of er ose of[s ho
: .19...,�`f or(Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b o any part of the State (subject o local
cemetery or other regulations), unless removal is by common carrier, in which case ransit Permit (VS No. 62) is required.
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