Lagoy, Mary _Form Q.P.. nl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Villa.e, 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 oo��
Dist. No4(0
1
' County Village /176--i-e _A I
or City (If city,give street address)
Nime of deceased ...per, , `�a-
Single, married, idowed, U
Sex Color Lz) or divorced (write the word)..744r. "•i1-- Date of D ath 1 1941""'
Age , ra 3 Years / Months ir Days Birthplace... 't/..a.. ..
Cause of Death
.. . . . .... .
Certificate was sig�d 1. -, a - M.D.W
Address... ..:.. . !•'� .. � ,.... —cam
Place of Bu ial (or Removal ...' .-0,:c ...A44 >r- - ... 72 T...
(If body is to balvmporaray d fill in spac ter)
Cemetery. Date of Burial a 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 registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to.... r., .-) fie. X V
(N ( s)
the........... . .. .. ... to hold temporarily and the body.
(Un take or person hav ng charge of corpse) (Into , rve, •otherwise dis se of(s how])
Dated. • ./ 19_1C.41-- (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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