Unknown Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 1N DURABLE BLACK INK. Registered No.
' Town �, E
Dist. Ncs."..li.. County.lfi� Al& t Villages
ity (If city,give street addiss)
Name of deceased • sift `• A
II
mgle marri €
5 �....Colo r divorced write the oar( Date of Death�t.�e ,,cr-its.4..19'��
Age..ke.7 ' Years... Months.. D Birthpl ce.. ... .
Cause of Deathr.� ,iiit,irk_-,-,w _,,,,� � -� iv
•
Certificate was i ed b �L .►4.e,... . _
. __ )
... .• -v�
_ M.D.
Address sw ,r4 ' I. -
Place of Burial (or'' Removal) ,r +
(If body is to be tem aril ld,ill in space later)
Cemetery .P.,r Date of Burial/.:.�-1L V' k 19..%:
tlf body is to he to porari y held,111 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 th ,,,above stated Registered
Nuii er, and on the ba ' f I HEREBY GRANT A PERMIT 44,
tiyrlLL geA. (Name)
thef ����' to hold temporaril nd wares", t e body.
(ll dortake r non having charge of corpse) � (I ov r otherwise dis e of[atnte howls y
L ate �
,A�:d�„�.q�.�+o� 19.¢f..,� (Signed) ... .. .. ._.. ..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject 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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