Olson, Ellen Form VS. Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
te 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. Registered No. _.._.....
Town
Dist. Nc1�, �� County-'F�/ Wit-Age..
/f�� (If city,give reef address)
Name of deceased ask:i:.X..i�l /��_° OrtV
AlSingle, married, widowed,
Sex... . ...Co1or..rs r divorced (write the word)IU I Date oj,Dyath ....6 .19. 3
Age 50 Years Mon*j Da s Birthplace ice-
" �
Cause of Death
Certificate was signed by re' M.D.
Address ge- ,l •-i �.i
Place of Burial (or Removal)
(If body is to be temporarily held,fill in ce later) L rk Cemetery .Date of Burial.... .,. . �,f/ C7
(If body is to be temporarily held,fill in space later) ---
The Certificate of Death containing the above stated particul s, having been present to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same for regist tion, have recorded it in my Local Record with the above stated Registered
Ne4., ---17 I
oumberr , the asistereoi Y GRANT A PERMIT `
,,,
(Address)
the .... . . . k to hold temporaries nd the body.
(U,0,ker ,r,, a ving charg of rpse) (In r �ve or o wiispose of[state how])
Dated19.e � (Signed) 1 .1.
Local Registrar
This Permit is sufficient for the Removal (and Interment or e ion) a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, i whic case a Transit Permit (VS No. 62) is required.
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