Rawlins, Fredrick Form Vs. Si. 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 CERTIFJ`,F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. �jA Registered No. post//
Dist. No - O/...County .. Vi1Ige ......A e-iree� G .t ...
y (If city,give street address)
Name of deceased
Single, married, widowed,
ilvt. •Color.? ... ., or divorced (wfite the word) ... . ... ate of th. • / 19 -
Age.........7. ..Years.... . Months....ar. Days Birthplace.. . . .. ... . ,. •.,P•
Cause of Death.-,-a . ., a .
Certificate was signed by ,... }`
Address Place of Bui ial (o Removal) y
41.1eft~"�
(If body is to be te'4'ariiy held,fill in space I ter)
Cemetery.. .... ... . . ... Date of Burial . :../F 1.9T
(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 a e ed the same for registration, have.recorded it in my Local Record with the above stated Registered
Number, on the as' ereof HER BY RANT A PERMIT /t
to .,. ..4 '
N dress)
the to hold temporarily an ...t' ody
(Under er or pe son charge pee) (In ov or of erw' is•)os o
Dated. b 19 (Signed)....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sub' ct to ocal
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is re uired.
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