Leery, Catherine Form VS.a1.. 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 CERTIF�9 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. ,,��f .......
/a/ Tewn /
Dist. No County .Village �P li
Or City (If city,give street address)
Name of deceased
Sex/y�� Q /// Single, married, owed,
(4r'.".'�'�(Colo( or divorced (write the word) ate of Death®'G 27 19
Age Y 7 Year // 'Months.... e girth lacCauso.f. DDeath , DaYs
4
Certificate was signed � V ,P M.D.
Address ,� ��Gtr..ti.r.1..� 1
Place of Burial (or y. 1 oval) ��itt.�,
10
(If body is to be tempo eld, ce er)
Cemetery �'� - Date of Burial PC€4.1°'lelf"..4.4.-'"f..-- ®—�'�'�.� 19 ��
(If body la to be temp. arily held, fill space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the s e appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acre the s e re ' tration, have recorded it in my Local Record with the above stated Registered
Number, d th sis HEREBY GRANT A PERMIT �/ ,--/�
to -
ddress)
the to hold temporarily and.. .. ..... . ....ik.. .` the body.
(Underta r ao hav charge o orpse) e, o twiv. :n�. of • e how])
Dated 19. ' (Signed) Cjj
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Sta (subject to local
cemetery or other regulations), unless remoogzl is by common carrier,in which case a Transit Permit (VS No. 6 ) is required.
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