Roberts, William i
Form VS. SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 CERT CA.q OF
DEATH, LEGIBLY� WRITTEN IN DURABLE BLACK INK. Registered No....
Dist. Nci Z 41/Count 1( Town > ke
y Village / If a .. t address)
or '
N zme of deceased •
�fj41...
j/� Single, married, widowed, I r/
SeX!.C4. olol`� 5�' divorced (write the ord) ��r/�'�d�" Date of Dh "LG �-'� 1g-,?
Age u Ye s U Month Id.Days la . '��'�" ,.... �-7 "'t'-,r-
Criuse of Death /' y
Certificate was signed by !'., M.D.
Address - ___
Place of Bui ial (or Re ) J`W�
(If body is to be temporar ly d,di
spa�jl r) •
Cemetery
a 7 19
(If body s to be temporarily held, space later)/ Da Burial e'er
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the sa appearing to be COM LETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accept the same f re ' , recorded it in my Loc ord withe stated Registered
Number, an n e a i f RANT A PERMIT /
to
•ss,
the �� to hold temporarily n _ .the body.
(Und er or pe n ving cbarg orpse) ove,or othe a of tat WI
Dated. ... ,Q,(„,.0 -4, 19 ... . (Signed) ,`.. ...
Local Registrar
This Permit is sufficient for the emoval (and Interment or Cremation) of a body to any part of the State ( bject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) i required.
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