Grant, Mary Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ivr 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 atter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. -•:"Q
Tvvvrt `t.,
Dist. No 64) County Q Village.. � . ..
City (If t give street a resa)
Name of deceased i��� 2/.j�, pp``,,A.,. .... �.
oft1 Single, married, W. owed, Li '
Sex L'... Color.t.er • or divorced (‘vT- to th word)!l .. .Date of ea �,//. ..19 1P
Age 407 Ye�ar/s��... /. Months. Days irthplace. �..I/77
Cause of Death `Z:.,44G,. �
Certificate was signed by ... I�, ,4>4- .Ivi.D.
Address .
Place of Burial (or Removal) 1;i,� p •
(If body is to be �jn�p arI�y he�l ,fill 1 e later) ,/
Cemetery.... ... � Date of Burial - ' 2 ( 19.1`A
(If body is to be temporarily held,till 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, a. . •i the basis a,ey�f I H Y G AN A PERMITto
40f �L�
•
N'a • rY +Address)
the •.. ' ... to hold temporarily an ` +/... '_f '.the body.
(Under or person h in barge pse) (I r ove or...erwr� soo • 7' : e how])
Dated .... ' 19.,45'0 (Signed) •� ,����
/ Local •egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the St to (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. .2) is required.
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