Hilkins, Martha F,rm TS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fUr 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. Re "stered No.
l/�
d Tu w n i1 '���? �itr4.L
Dist. N c���� County. il/ �T� e,. ,.7
p (If city, give street address)
Name of deceased '?"41f/t(i'e -' /
// ale, married, widerored,
Se�_.� (1Colorh/ l or clivnrc 4 (write word) '" Date of 2heath. 4°4- I 19.Y2"
Age (P$ Year ti 0 M th 2- • Days Birthplace. . .. / V44.
Cause of Death A-
Certificate was signed y- .
Address �/....... -2.
Place of Burial (or Re oval)
(If body is to be tempora eid.till 1 ce Inter)P ,/
Cemetery A � ate of Burial... 19T/""
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been p esented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accep the e for registration, have recorded it in my Lo a rd with the ve stated Registered
Number, a on the s th f HEREBY GRANT A PERMIT
to
the to hold temporarily a (Address) the body.
(Und ker or person ving charge��oyy rpse) teil•�•,o e,or o rwi nose o tate howl)
Dated .rl�. 19...`�:.s�/ (Signed) Local Registrar —
This rmit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the to (subject to local
cemetery or other regulations), unless removal is by common carrier. in which case a Transit Permit (VS Neb. 821 ;. rprmirorl_
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