Pingrey, Robbins Form VS.8L 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. egistered No.
Town
Dist. No,J.4,6 ..County.. 44,1 Y 5 Village IV
^ ... If city,give st address)
Name of deceased , .. ... . „ ' ,,,. .
Single, marrie widowed, /f
Sex ...//. ...Color CO or divorced (write the word). iL'W..' �f' Date of ath.. ... .. .. ....../.. -19 Cf Z
Age 62-1. .Years J- Months.. ../.o Birthplace..... rxe._ `74../Cause of Death ����•( ¢� k.::,,,,,„
. ,fi x,. ...a
Certificate was signed by �! M.D.
Address 7�c��� • f7 Z�C
Place of Burial (or Removal) —a,(/,� a-t 0-)'. 7.,,..
(If body Is to be temporarily lcV in e late
Cemetery L^ �'YY! i Date of Burial... l 7 19..ce 2_
(If body is to he temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been p sented to e, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for regi tion a recorded it in my Local Record with the above stated Registered
Numb nd ma sis,tlyer�H Y GRANT A PERMIT+ ��
to 4 C7�T'Gr .1, �Y-4r5!u .... '. ...ir.y
( e) dress)
the....... to hold temporarily an the tr6dy.
( T maker person ppa ng charge of corpse) Inte mootberwise dispose of [state how])
rated L.. 19..(4.`_ (Signed) .c.1//v�//�� J1
ocal Registrar
Th. ermit i ufficient for the Removal (and Interment or ma on) o body to any part of the State (subject to local
cemetery or other egulations),unless removal is by common carrier, in hick ase a Transit Permit (VS No. 62) is required.
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