Dagles, Sarah I"orrn V6. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t This Permit can be signed only by the Loyal 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. 3,a:7
Town
Dist. No.. e/ County Gi?d€�.-? -tl V11xge.. ..• (L...14,..„." .
�!g25"421itez.er(If city,give street address)
Name of deceased ........ . . rf►c7.: 7
Single, married, widowed, , �/
Sex Color - or divorced (wr the word)...... ... Date of DeathQ.�/ 4?f.�19. �fu
Age 1'2- Years / Months / Days Birt place....c ai,ei , G77• ?-
Cause of Death.. .. .... - ✓moo.- �/! ,.z +e. —. .. . . . -4�G 6
Certificate was signed by M.D.
Address C .t�.,...'11..:..�
•
Place of Bui ial (or Removal) .... .... .. .........
(If body is to be tempor held, fill in sp er) '
Cemetery.. .... . ,,,w.2.G,,...... ......... Date of Burial.•a . e 01,, 1.9...`, .
(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 accep ed the same for registrat' n, have recorded it in my Local Record with the above stated Registered
Number, a on the bas's eof Afkg.RANT A PERMIT
to.... ... (T0.-- ). P7. 7.
( e) ress)
the........... . .. .. .... . . . . .. to hold tempora ' y and d the body.
(Mad er or pery� ving charge olI�,�c rpse) , e ove,o of wis di • [state how])
Dated.... .. • PS 19..`�`.�� (Signed)
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation o a body any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Tr sit Permit (VS No. 62) is required.
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