Achenback, Jessie Form vs. 61. NEW FORK 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registere No. '.O 7
Dist. No �� ..Q ..County �, GG W}}2tge 6
- >ixiteii-or City (If city glue street address)
Name of deceased
�y Single, married, widowed, h ry ,/�
Sex.74i. Color./l.: .ori divorced (write the word} TLC Date o e th. ... . .. .... .. ,,1/..4. ..,,5
Age_ 7? Year ... ..iti Month ir Days �__ -- . Birth ace. .
C use of Death... ... .. . . ..../.... . :/. •GZA .. ...... .. .... . . ;.. ! Lk
44
Certificate was signed by Q¢ ../ •�
Address
/
Place of Burial (or Removal) ...,',�,/... er. .,....-
(If body is t9eintemporar3y peld,fill in spa later)
Cemetery :44a...l 4ze..e�.. .. . . . Date of Burial 01461141641r .,1 19....E
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the abov 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 recorded it in my Local Record with the abovee stated RRe-gistered
Number, id on the b sis�er�to di' a H EBY GRANT A PER �,�., di xj,•GCs�r�o T
(Nn e) ddress) G
the ..G.(,.� to hold temporarily and the body.
(U rtaker �, o„P,helve of eornaP) (In o ,or h se s o [ ])
Dated.. . . .fir!...,, 1.19... 3 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or 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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