Ferguson, Byron t,:,a \ ,;i. 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) or the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registeredte� No !�f^
/ / //� Town /4 /� E:D L 44-e—
Dist. Nc�(JUr Countti• �'� � Village..... ...
S77,040-,--
.... or City (It city, give street address)
Name of deceased ,:Ingle, mar-pied, wilaweSe 02/1 q. Colo or di*ef ed (write the w Date of Death. 19,4;
Age . - Year Months. l G Birthplace 4174/
Cause of Death .'`
Certificate was sign c by.�. ..../../ 2.... . .. M.D.
Address' lr� zu-Kr. �„ � „,-0 'e,�.�`1t ---
Place of Burial (o'r Removal) 1
(It body is to be temporar eld, till I s ace later) ''
Cemetery „ -le.. ... i( !' Date of Burial... ? 19.T//i""
(It body is to be temporarily held,till``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 accepted the same for registra •' hay recorded it in my Local Record with the abo4,4,..„
e stated Registered
Number, and >d a bas' y�8f I ANT A PERMIT Z/��L�'`-r-K- -6y. /��toC Z �/
es
the �� to hold temporarily and the body.
( ertaker or p n having char e t cor se) (In ve,or o wi p se o to how])
g,9 P I
Dated 19. (Signed). .. .. . c .
Local Registrar
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. 62) is required.
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