Nobert, Francis Form VS.e1.. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
it 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 ' tered No.
,,��// Town
Dist. No d....County....-1 Village
()r City (If ity,giv street adores )
Name of deceased /.
Sex.y�, Single, married, widowed, ?
.Color... or divorced (writer word)k . . Date of Death,,zr 6 19.... .—
Age Q. -7 Years Z Mon s .,—.. ..Days 'rthpl ce .2 ��
Cause of Death
Certificate was signed by d, - M D
Address
Place of Burial (or Removal) c5 i-Pyj,,, ...
(It body 1s to be temporarily held, 811 in spat I ter)
Cemetery a�. .C�Z. -a7i �/` r Date of Burial .. / 19...�1::
(If body is to be temporarily held,all in a ce er) /
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 LA\I",
I have accepted the same for registration, have recurded it in my Local Record with the above ac_r, _
stated Registered
Number, on the basis ther f I HAREMGRANT A PERMIT ,.
to - . .�T�r(,!Zl1!1....
( e (Address)
27
the to hold te,ill�>rarily and
the body.
(42..aLt_-
rtaker or person having charge of corpse) (Inter, rem e,o otherw se(IT of(slat ow])
Dated • Ca 19.. E (Si;.ncd; GC .� �G ...
Local Registrar 7 .1 S
This Permit is sufficient for the Removal (and Interment ,-r 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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