Hall, Millard Form VS.BL NEW YORK STATE DEPARITMM}M�NT OF HEALTH
OFFICIAL BURIAL (OR RMDVAL) PERMIT
Sa' This Permit can be signed only by the Local Registrar (Deputy,or s bregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acc,ptan�e of a CORRECT AND COMPLETE CERTIF TE OF
t /
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK, j Registered No.
k
/o% Tom,.. � tth�
Dist. N (. ..County V.illege ...� ; K•�l
A/mrseac,ir City
(IY city, give street address)
Name of deceased...
II,, __ ���� ��� ingle, married, widowed, yam,
Se R ..Color o: divorced (write the word)/�-��J Date of Death. 4+ 511
Age 10 Yea l ....y th ...'....` .....Days Birthplace
Cause of Death.......,,/.... ..
Certificate was si j / `.gyp M.D.
Address.. r _f •��
Place of Burial (or Removal)... .1 �� r "oe
(If body is to mporar Y he 1 in spa )
Cemetery.. � ��I ..r�I�I... Date of Burial... // 19
(If body is to be temporarily held,1111 in space later)
The Certificate of Death containing the above stated particulars, having been presents to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have a epted the same for registration, have recorded it in my Local Record with the above stated Registered
Number nd on e b isr R Y G ANT A PERMIT.�0e// Al 1�`�j�
to /'' t !�C �CwnGr�t
.. . ... .. .. ..... .
( me) ( ddress)
the • to hold temporari d4„ the body.
(Und taker o persog?aving charge of corpse) remo ,or then so howl)
Dated / 19..e/,/ (Signed)
• Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremat' ) of a y to any art of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in w ich case a Transit Permit (VS No. 62) is required.
C".-pet 0 ° w ".w •N N.00 g n o p ro w o o n • t..°`� x'ef ti N w , n o a _. ,.H cn •...
c ',j,'� `+ -, v00. eeo EC7elr, ^"�-... ,........;,...a- 0•-,° .ro,Oq ynorog0.0 „ ao.:•00TO >*>M 0 En wO 01
•
'2g' a •ro`a'o wn. o a y w� n°•a *a 0- em••c.,� n n 5 y'0..0 N ab w•eb o ro 5 m. �C< R• ° Z
xi « -t a 0.„ a .. ro N D n m'-'n a'+-• .- Ni o ,ill
t„i�io m2'V w 0 e e
a ml soe 5'° ', rt. -e c''o -roi '° t•o:-0-0 o' 0 o"O ..to �, 8'�~ G -w, ro R p:,, m o �.o,w•, ° 2-.4 E e �2 p a T d
Vl N ro C ro O N a ro CD CD �, ?a n ro 0
�" k ,a.E,b rw, roo 0 "'o ti= " p, °: N e co• ,n tOr,Nre 0 ��s »'et, . 0.a `° „ w ob r. M o ".,C�p �7
; ,.0 •H O ro ro a-, O-O P-N n RI W 5 7 0 w p•rT N `t < 7 a.'
.a ro N 5 0 ro < w ° Encn
a m o�.t � n9N �n for corn «ooppvro �x v'cw � a � nn �.� i� ezHGS vJ "CIM
200-0 ..NSroa•o .., a 03e w < -, C roo. Fs a'. .. roa.< o
ea n _;Y,ia;ro E5.ol.)'= wa °,WF 41g•eC.t. A , roN n ..�.o •-9.10•e.rai � 5• �Ye iVZ
y ••, 0..--n CD a N o ro r N �n p, N ro , w p ►�R
tr.,0 •, 1' q0'0 nae .ta0 fD g0'0'0 • w nw co ^ *„•1w Nr`oq .N
s �a oq a a n a a5 N e ZN ro '''n' • °q n ?; nR :. E .a R C�ys� rim
• 0 of ° •O r> a2f aM.,ro+O r,•a•0 ro p, -• [1 .t N 0 �0 .+_.3 w 'E O n w O N •�/1 w zr..p „7,tZ
< n ro rr S < N ro R" KC w 5 'q
O. N•b G •-t N N'ro G '•t w w0 a ti .rroG'ea rob * " ° C• � ° � a�� "' �"'•.» � �� � 0 0 ›.0 rrt.j
,e ep -, �oQ = awaoF.„' M`5a ° 5 Iiao
55 O O .+.0ONO Di" ., . p G'7.0•ro - w" a <0R g:
P.:• ti o� wory � » =° o=o ^ r.^'rv5 ,rot Vint. no.n0 ^o ° rown �0-ro �N ii +nw �'•a'�.40 ^' �� °CA
C .491.4.1 ro ,,.'y=,. •,y7•• O N rc .t N N O.+OG•ro N W r, O N O ro a 1, a w `.� .� ^i...ro tr1 fro►•/ C .•, Z M
0 rT. wro aO, nli Ga ... P.r' ,, 0 w k •, a'a CDC w '^ 'n ro4.S' .n�c9� OO �t M pH ,y D
y[h2 a.y O a'- ..Nb �-t G w '•t.so w• '0 ° ro :? O ° m ro b a- „6 5 'gypap n a ~�
a ro' w a y y O •y ^, ,t ID A
e p y W 'd w 5: n n A •ro L1.»,G ro e • •,
•f to `+,a.fro a n ro N ", n 5 n O 3 G, .t A n0 e n� �, re a O p, p�' �T� �H�*w �' r..
''�H •+ scwNrro, co c' mRo .+n ry0aov0.Cn .. �,.dw5ro .'GG aa.0rb, m-, nk9 E ess- 2: 0:0
r .n. c �.o o + nro a 5w 0 ', ^+ w.n .-ti �•oww �,y' c .t ?o Tp }•� _
s .Aj ".aaa...roroa...wro'w, a'' 5.-, `<.° row 5oNa0N w ^a-o `e0 r° Lr •„., n c. =� 2•-•Z
m 1-3 4. 5 a?°q a-. a 5 5 o a•,...,.oa .a •o ro o 0 a N 8-w w RR 5, 5 f� 0- ='ti
b0 a * z' 8 < wwtn "•no.0 , a <na ,..° a ' oNv°:;tN y p�j� 8Nr/ 5rw�, a-•T,�s a Fits '+cl ;; =�
R1H,. ?;N •--_5s'N 0 aw r° O ro 't G•.1 re re E •_'p'0 a- eb'C N ,y .Gt CD N 0 0.IL'. r�•' 0
.P'T1 a'•-O„� wa= 0 11.5 a�ro E•ce3 wN nowa o-G, ° ,.'nroaci rrn " °' w ocr p�C" a CilE VS w? w
• t+7 01 ra, Nyn *wa)..4 o ..roa onn - GoSro yN <'O -, � wroro _.a.ev ,—, eg- .N c7, 2.n0 e M
auzizs rr w° w��-roino�w � < moo °, ''.��e ororoo n0aa O �o wi 'tiew °': v "1M
ro a a w ' a 0.ty < o•b a,''ti rr�qq �" to 0 e0 g. n M pj
C Ci7'TIe n G .p•,q ..O a•N ro .- y .°j'd n r,"0 y. 'ro N 0 o ro 0 ••i"• r�C.a-A 0 0 .M1t 0 e
ro .t 5 ro '"* v•7� rn:r Pt b ro�n ro rd, G co ... ..•" ° c a' a ,., 0 � w •N. o:
r2 �� = i,-,- nOrSo o-n w.o^i � ° 9 t, 5el, a' �•.s•G _.'-'r g.,`PRrn, ti � = ei%I► p,T_ Z.a• �"l p.o . r.1 n 0r�. 0
d.?�1 MO _•N."N rG~. �'X�'[nrt �' w ° fG ,yro N •ta w '. .to -•«:O�•"1b 0a• y a �� '~ v MM~Z
o re rot + ro � 0-ow ,wtronp � nrp O .reoOR ., *n ~ a � O � reo � roa - GN.Oa ro » e�0 .�j
fwr.R pw �.r~e n72 ro O r�o'd ^" ,g.0.0 G w a �o'b0q X in o•ro "t ro Z N 7�•< w K p•O.aH,r a E.n _�qq 2••
5 i �t•+� n n 0 O O N O f a t^ .pro {5.a',P., N .y O Q;-.a. .t 'm 7 n P. a o-0 T ,�'j.2
t.e. "' 5 o N o ro •," w o ., v r, a o .t - .1 ° o a 0 < ro 7 ro "G PA »rp' Vi H». {NNE !1�
0 O ONa'', a0..=•-t nuw, ° -. n �,43 .g-,-t w.. wO �, .-n,0 w0 w .°..` .•n R O •�•ffp \ n
+ A - N ..1 Rn ry :+"• w e p O •-. G 0r, ,•wN < .n . G , �.
er -- p .. co O,p w O Zr) 0 0.n .t ro T7 O .t !' r•ti e b ro ° < ro '" a-.`C Cry �'• e a.." t.,�,
Aa .r n'p ry N O w a O.y.• p 'CTp v-�i �'� fe p,W to y.< .t r0, .-, CS,r-•O 7,M G ° T^. - M�.,
n z� n.M .+,.�7' El w•n O in .O E. 0 `03`G aO�C «Ai 7•A * row ..N N'n o. <' •rot N ." H �•«
0 e OM 5 A 8 p,•w ,,,, .n 3.a•a '-"ry '^` w-• a a'.0 �N h 0 O'''S-W 0 n -.N"''a-t w w �;'e ',, ^�^
:'"r��e :iro ra, Cr.•.oroC� "O w7 ""' a•F•GOab•y••`7 9eC ro.tpOH �, O -� ON 'q• ^`C tie cr., Y+
ti F g ° O.G p Cp't.�' O- e`e ] rc ra, ,.�`, n O �• 5+�, m ` r° "t A G .r"p w•O .N.',O r° G'p :T1 r0 z s CAI
0 0 _•« G'•<..v6' .w.° :••" •v�•- '"' " Z�, v' W-.0 .4 aw 0 ^Gi o..5 �N n•O N S O ro •_y �d17
A'D.0 w'� n .Y ro tv?.c ao O r0 -v, ??w 0 �.g7 o o i�.n e<, Z2 e G o' n.° 0, O re C0 6a8.,77y 'fv`. 0