Ploof, Henry Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ivEr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Villa.e. 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. R istered No.
1 Z Town
Dist. No a�? �(ounty..,,,�r�,,���;111yt•�n'1, "Vrtrage..
epp.et{ (If city, give street a Fees)
Nime of deceased
Singl , married, widowed, //���
Sex Colo or divorced (write the word)-2N' Date of each. l 19.. t'
Age. d..7 Years.... .. ` ths...i 3 Days t Birthplace... .!a-+-1r.--.. l
Cause of Death • ,.,, ,..4,41.,,, 1
Certificate was signed by ,k,- ,+„ M.D.
.... .. ....
Address F
Place of Bu,:al (or Removal) ._
(If body Is to be temporarily held, fill in space later) ,
Cemetery. .... .. t L t A Date of Burial eV 19...yL;
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been present to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I hav accepted the same for regis ration, have recorded it in my Local Recor with the above stated Registered
Num , and on th basiy'lthei of HEREBY GRANT A PERMIT c�`...az
t0 .1 V .vim.
the... . ess)to hold temporarily an the body.
(Unde r peso 'n c a g charge of rpile) nter, mov se dis��ose of [state how])
Dated.. ... 4...19...q. (Signed). .. . .. .. .: t
Local Registrar
This Perm' his sufficient for the Removal (and Interment or Cre ion) o a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which age a Transit Permit (VS No. 62) is required.
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