Taylor, Clinton =PLACE OF DEATH. DIST. No. PERMIT FOR REMOVAL AND BURIAL
(To beaInserted by Registrar)
•
county oftol THIS IS NOT A DEATH CERTIFICATE
Q City or (nt�liforuitt *ter hoar' of tgrattb, Bureau of Vital t,tatistirs
g Town of �+ Local Repi r ber
U s or Rural Regis- �Ti (No.----1.41 Plymouth__Amet.; Ward)
W tration District
g 2FULL NAM - Clinton Frederick Taylor
Ei
Z PERSONA'e *AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE °SINGLE,MARRIED,WIDOWED, e DATE OF DEATH
OR DIVORCED (Write the word)
<4 Male White Married January 28 19_23
Ig °°If married,widowed,o divorced (Month) (Day) (Year)
;A (or)WIFE of
HUSBAND of Sherri a Taylor to r t I HEREBY CERTIFY, That I attended deceased from
a J 8DATEOFBIRTH Dec. 4 Jany 28 2
19_24 to 193_
-4 , Ma-y-- 9 1 88 Jar _to iz (Month) (Day) (Year) that I last saw h im alive on y 2 19_23
I-i W 1 AGE If LESS than
CC
Q 1or day, min.
hits.
and that death occurred on the date stated above atlOP m.
() 33 _years7 months_ 19 _days The CAUSE o>' DEATH* was as follows:
__ __ __
H rt IA °OCCUPATION
(a)Trade,profession,or District Manager Angina Pectoris tittle �.I MAL
• F r
z
< (b) General nature of industry,
1-42 business,or establishment in
which employed(or employer) inauf.i e1aoyr
ED a Walkover Shoe Co
Z W (c) Name of employer
I-I Z °BIRTHPLACE
A ityateo townr )country
<4 cc Luz e rn e N.Y. (Duration) years months days
w 0- 3°NAME OF Contributory
Z W FATHER Frederick Ta for
0 _ (Duration) years months days
1,.I I- F,.y 11 BIRTHPLACE OF FATHER jolty or town)1.14 18b Where was disease contracted
c-, 0 Z (State or country) En land
►-1 if not at place of death?
W "
Q MAIDEN NAME o No
OF MOTHER Harriet Brown Did an operation precede death. Date of
13 BIRTHPLACE OFMOTHE cit or n)_ Was there an autopsy? No
(State or country) ' `er town)r-IC
1 1fl.LENGTH OF RESIDENCE What test confirmed diagnosis?
aAt Place of Death _years months days (Signed) V 0 n.than Green M.D.
a (Primary registration district)
(If nonresident,give city or town and state) J a _
St(Address)____
H In California year's months days "State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES,
~ How long in U.S.,if of foreign birth? years months days state (1) MEANS OF INJURY; and (2) whether (probably) ACCIDENTAL, SUI-
124 g CIDAL, or HOMICIDAL. (See reverse side for additional space.)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1°PLACE OF BURIAL OR REMOVAL DATE OF BURIAL
(Informant) Cla.ex_ri. M Taylor Glen Falls N.Y. Feb. 4 192 _
its (Address) 14Q5__Plymouth-_AY6. 3°UNDERTAKER EMBALMER'S
Truman Undertaking Co LICENSE No.
, Filed 19___-• g
BAN Subreeatrar
'1`9-- _ , 1919 Mission St 496
Registrar or Deputy ADDRESS
-t LOCAL REGISTRAR'S PERMIT FOR REMOVAL
N. B.—This permi "alcan be stgned only Toy the Local Reb strii TDeputy or Subregistrarj or the Yrimar'T'Regtet-tle„^D•er sl,A 1,r '
occurred after the FILING and acceptance of a COMPLETE AND CORRECT CERTIFICATE OF DEATH LEGIBLY WRITTEN IN DURABLE
BLACK INK.
A CERTIFICATE OF DEATH having been presented to me, and after examination the same appearing to be COMPLETE, CORRECT AND
SATISFACTORY AS REQUIRED BY LAW, I have filed it with the above stated LOCAL REGISTERED NUMBER, and on the basis thereof I
HEREBY GRANT A PERMIT to the above named undertaker for the REMOVAL AND BURIAL OR CREMATION of the body of said deceased
person as stated above. In the case of death from a dangerous or communicable disease, the burial or removal must be conducted according to the
rules of the State and local boards of health.
d\
Dated 192__ -^•_; Local Registrar
By :ac,....„, .,_-,,, Cle E.
This permit Is sufficient for the removal and burial or cremation of a body at destination as above indicated (subject to local cemetery* r other
regulations). "".
Endorsement of Sexton or Person in Charge of Premises on Which Interments or Cremations are Made
Date of interment orareraiiiiian___ �C '4+e- / 192 �-
(Strike out word not used) �� are of person in lat'ge of Ce tery,Crematorium,etc.)
_� -
(Name o n tery,Crematorium,e )
Persons in charge must return this Permit to Local Registrar of his district within ten (10) days from a ove date. If no person Is in charge the
undertaker must sign the above statement, writing across the face of the Permit the words "no person in charge" and FILE PERMIT WITHIN TEN
(10) DAYS with Local Registrar in the district in which the cemetery is located.
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