Dutson, Harry Form VS.SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
i' 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 CERTIF. T. OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. qq// c
1-8a4
ta ;r/ ., f
Dist. No d/....County... �G� �/.�IGI V-iiinge..,.,1 t1 , .. R...-
ity (If city,give street address)
Name of deceased
Single, married, wi wed,
Sex....1Jy olor or divorced (wriie he word) ...: .... ......Date of D h. 1`',1�
Age F a Years.... ..rf Months 0.2/ Days Birthpla .... . .. ,�••
Cause of Death... .. ... .. .... . .. r
/,,3
Certificate was signed by 11-.1
Address
Place of Bu7 ial (or oval)
(If body is to be temp held,,fill in later) ll
Cemetery .�+C..�i{.tJ� Date of Buri ... .. ....17 19.t
(It 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 he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have r orded it in my Local R ord with the bove statedstat Registered
Numbe don the b si reof I E A A PERMIT �/`���.�►�....+(+�.....
to
' ( as )
the to hold temporal-. nd Ze bode-.
(IIndertak perss ha}iyg charge o remove,or�tFyErwis� state how
Dated...... � ;rr✓r - /(u 19 / (Signed) (�i�
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation a o o any part of the State (subject to local
cemetery or other regulations). unless removal is by common carrier, in which ase a ansit Permit (VS No. 62) is required.
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