Mack, August .i,m v . 61. 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,
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. Registered No.
'/�-CY Town
Dist. No ' County Village
. (If city, give street address)
Name of deceased _
Ingle, married, widowed, �� '-//
Sex - olor r divorced (write thew L�
rd) Date of Death 2 'Z 3 19.7"2-
Age G Years onth Days Birthplace
Cause of Death G� .. •-•.
Certificate was signed by M.D.
Address i l4�
Place of Burial (or Removal)
' l�,o
(If body is to lietipiporaTily held,pll in space later) �./
Cemetery .lam Date of Burial C;b-zr--, 6e4....
19T Z
(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 e for registration, have recorded it in my Local Record with the above stated Registered
Numb , and o ba ° hereof I HEREBY GRANT A PERMITe.4
amel (Address)
the. .�-� �'am to hold temporarily a,i the body.
(Unn5 �^ or perso;hang charge o corpse) �• or of dispose o state how])
Dated V 19 4/'�� (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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