Frasier, Luke Form vs.ei. 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. gistered No...._.-___
g /y Town �]
Dist. No ,� l County �i}} �'1 .,
'' ,, C i ty (If city,giveName of deceased c' l., 9or
ec��.� Single, married, widowed, qq s,
Sex.fli1 c4Color..10 or divorced (write thh�j word) Date of Aeath.. ..... P""�C 193/.3
Age...6...3 Years .0:,,..... .. ..Months.............(?�,...Day ..Bi place..av7
Cause of Death , 7-i&z..../A.. �'Certificate was signed by .. J... M.D.
Address _�_
Place of Burial (or Removal).��ii,, Se f
(If body is to be temporarily held,ii1.ace later •
Cemetery ,, . . later)."
-:(. 0411.,..Date of Burial..[ w1,,. 2/ 19.. a
(If body is to be temporarily held, ' 1 in space later)
The Certificate of Death containing the above stated particulars, having been presente o me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY S REQUIRED BY LAW.
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num.;, and o. basereq�f Z H REBY GRANT A PERMIT ;�` /�
to....... . Y/ ! �scr
the... . ... , ... . . .. to hold temporaril and . Address) the body-
.......
` (Uip rta er or Dem?having charge of arise) (In re o otherwise dispose of[state how])
Dated..... 0 19.. .. (Signed)... . C...
- Local Registrar
This Permi s sufficient for the Removal (and Interment or ation) f a body to any part of the State (subject to local
cemetery or othe regulations),unless removal is by common carrier,t. wiz' case a Transit Permit (VS No. 62) is required.
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