Codner, Merritt Form TS. Gt. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Fr 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 alter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No
/� �
Dist. No ‘.Q./...County GG!� �e�vrtr-+
_Vi4.lage...7f -) ,4 .,:% �,..? .+raj .�..
or City (If city, give street address)
Name ofdeceased 24. 1,441- Gfie,e .....
�Single, married, widowed,
Sea�,f '
Color o;- divorced (write tl; word) Date of Death... ..,,/' 140 119..g.�
Age ' Year r Mon s / Days • Birthplace..,rra4!!tzt 7.. 04� x./
Cause of Death... . .. . .. .. . .. ,-14'Q .ec.I
Certificate was signs y M.D.
Address
Place of Burial (or Removal j..� f!�FCl... .. ..., . j „L.l..l.�
(if body is to e t mporarild,fill Bp later)
Cemetery.. t4CrL rti Date of Burial... .. c9,0 19. ,1
(if body is to be temporarily held, B11 in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have cepted the same for re istration, have recorded it in my Local Record with the above stated' Registered
Numb , and o t as " I HE Y GRANT A PERMIT
of JK/'wf6 4/ )1 7�
the. � to hold temporarily and/ ��li�dresa) the body.
(lit rta r pe so havi g charge cl corpse) .:11( ov or eerwis son o state how])
Dated 1....19...V.. (Signed)
Local Registrar _
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Stake (subject'to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
rHv rJ,1100to w5r
,,, y Ur n o8 ro3 m ° o , n r,oAa-ro �rDC•na K en cr. Q•.,CBy '' f,,..es
d Q,
v,
C
dCZK ti9 " =Ca sA ^ e 07,in a •`z -O w —�w- a'», A,oa w naa a3 E, n yo o w ›A *� 'fly w
{�
•>g RR ;18O ^ AWxA9 n,E5+Sn54." •�coroF ^° •A ' ro � np
aaco� oti � A �TGowg ° A , ym °C C nAvqmZfpEzrl`: p % 0 OZi o ' `<roa ~op.0 roywo ., 'aAaA N�N,naI ("p n ^ oq �^ 'OAA
� fa w ° '-, p p,w ^t � :'O•W rOo••y S'�O Wes- wn , •tI C �'o ro° y , M-p•�W 0 vO X7A R 0O ¢,A
oel t [A yA O� tiA � A p. ^+ , A- C cm ..0 rV 0. r.pwuOyOi'y r pQC, a
0.
•
eem^ A. w� caa¢ A ' „ A r« ' k t nraoa "sO '.t = a � ' ° AA A r,N. o rn £ •oano•o :' C1 ar _d .p iI1.° aa , a-0acwA - wg » * ° y =.» , ea .a;AWoew ° '0X XI "CA p "Cy "ja", =; 3nyfg rov0 *aodnv,, .+ ,. -v: p. Ca .tAa 'no • AZ.•jd ra20E0 ..AA '�a-'' a. pp3r c -ta A " wAr .. —ID aA a' n H03•o Yn 0e 2F.;y.: oa co A.$.5,?,7^§ am ..,..4 P-G R'0 T.b o• ,t Av, •F,. ' y .'� " C * a"ny e o wet » Aa„.
F.
11
S.O " f . wa O nN ONpr.+CA '+ n0w A wAZ-•0 :I• n " egEo � 'iIA ^' gMy as ....0 C d 0EA. LTILMo aa < a a'At a.0 y A V' �, A n y A, . •O'' .f ■ r '12 qO .° A p.wawO '`'0 so z.Q, C co A 7 M .e�C
° . oet• y RA o ° � -
,.,'1 * Z<'*t A =nA ?
:% nb - � a;• a .cpc _ ^
r ;mo re » ca y•Aw Nc rna pyan R Y . p> ? ^ OW _ n.0 A C •, -,Oq Caw p•O ., cr— ,„ AaG...A.wa O En .t a " C ° yO "G a Z ti O 't'AA y syC ca pAoo .t 11., .» o•. yny wgwEc 'tR0 � dp' a z , "I� —
OP
1.
' �� a w_ ^, •-• _ . A...-,
'^, ) pA e S'T a nA
R C
.+
B
r
'r
7� d wapro , . a5.nA. 04a. � K0 , nPA. � w�wa r'ro ` w °,o " "= 4R^ 1To.ew?•"� a ^ wwnC . 0(/,- � 0 ° 8 rt -* = ' aiat..,, CD e . --.-
CHw 'w onz''- ° A A y ' ° A --, y Ap,nn •TaA � .A e r] .Ayrl< C .n •
Z�a =x arvOnta •� w' ' •aT '� o0,• F'a ., G°rg py tiC.-T•9Mti �M p . �' a nNy .. A pA - .,0nOp " «pi a^ e): H�XO^ �0mnoa xNn wA: t ' w .ww ° '^AoCre a ° w ° ^ C8 a�3�,. 9 "' .-3 o " ry0y o.non •-Q•M ., p, cr0.,a� or% noE ° �G iia o9 C rD x , n 7'O ' • r 2=0�`3 ,1 : YO m n ro n A �• nA0 • ? . c b n ^ rig "aN ,Eh 'n.a ^ oF., a A A -4-g ',1 =„T O ,Kro "' :p, ,,• - '4 ,eG � onir U ` 2(0C , � C 9 0W p " -e ..I s.• a 0 waHZ • oq 'z 'OA0, , wa ' . p » 2 y'NA g "'1 0'R2 "e� oa. � � t o .. ^ � boy 2,� s `n-1a " �r YX40 $ a ° A, oaa ti wo 'tp, A '' 5.yN`< = cyrW
•
.' 0wS no. ° t r � , ^ " m
'wog •
c.
c.
- 2t �.4o_A .-,.'YL_ J.•y •-n, . io _...„,yc:a-C �4-o-R �ta.w. , 0r3o ;ollFo '-, n gq w 0• r 'taa' n rn 'o•Rr's no w o :� ,-'-" non ro w o '. o Cr1 "p u' . n ...wp.'�'p o r. n a onn CO ., y <ro 't w aron a $ ^ . 0 yAAti wQa a •orHrywK "JCi7� Zz.. a•A0'ya'w A , , -ti'- �'c0oA .. c =* R' co 0. a ^ .r0-' ro ..• ro • aa' �• a5 < ',d ro y' z+'. 5.R"`‹a.».o- .0 r1^ o '3 3vyOWom' Ci777 a Cw ..O z-y C $u 0 ^ x'O rw uA O _pD A'd ,..^t ,y t A :T A O o .0:^ 0 m > CA
o r :t .Oq " ya .ry: A Aymo So -A. —^+ w parA tCA• i - A r •
X A ? Ag ,. `AA . og � 02LI5,p Is•na' n ° g � A ~ oaFG.M - a ; r• g 040 A = .no.,w ^ n = ' oNy' O 'j a. .e 9'0 1 .troy cn n "jw .K .. lry t'y z�.O ..o nW a. y., A, 9 °y y o- _..t A ° . wa• '4O •CO ' A A Q. R aoAv0 A '+ 9' ",7,..Nfo wag • W •."-'re . a ° raA .,-AC5'- o.y.o•z A H :. 0 Zoq � ro J . a P. nS AA0 " < ap:ay.., A «.'SOm ‘C ' Pi, 0 ro 't : aO "' oo° y•x .Cro �•� O p:xe w . oGAG. .A ^rO H yo-�ytl 3ay , ,•A '., -, y O C a. 15. x ►0e�0wyAw,, nroO •A ° � b �a � `t � H nw 5.~ w` i, Av w .., w ty 0... O• � YCr
174
11
« � oy ]' p.• 'n' • y^' A " % A'
.. . On
' .. f0 "'b ,•.NA n -• � a'ar rerop 't '4 ° A•C ° ,oy < ..,e A G p,- a r" zm o " A E.
.... 0 .. A p•p w oco A °. t O. A p' yC' e aA a At ° g '- o .' > odoa A o �y o ° acaw = p <oy w ro
` 0C i � o yo °
' *-mowmbOA ."•A -no ...' a•p ., oz K =rl•e .. �A - »,D n' P, -,. O .,A• ..,� i •A �yp AO a 0. •., .w wyp . oy. C �.o At O p:^1 � 0^ a : n•s awaw y 7row .t- � .a.y. a 9 C ''d ..,O v'p*' '* •• m e C K rrfC co ..aAs ra � ° ro » Qp ,t ° ' A O �� o ,
rOA 1G. n roA 'tix0 O o•Ca y CA o,CaAY^+^t n�a � .wsy � n0.AwO • O aro ^ d52 03 '"'.MC,{'y ? C° aay 7-el � yy w .-n•w ay . G.cAo• nOw OA
.i9 y ` . 0 3 .-." ^. `. [L0-m.r 0 ', '.*1-• -.6 .4Z@ ° . 0TMco W1 s . C„ on
k o .r.7m•- 6 0 o n. O n ..•., as O .1. OO r. . n n n en re .ro