Schneider, Anna i orm .'S.61::. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
12r 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 CERTjFICAli OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK
INK. Registered No. J I)
�` .yC y �,•1�,1.ar..� *c.... T��. ��"2 >
Dist. No.. , � ount
C•r
(If 'ty,give street address;
Name of deceased
Single, married, widowed,
Sex Color..4 A,�.. or divorced (write the word) L 6.244,
Date of Dea ... 7..:. ...1f1. lt.6
Age ,,::....Years Months ,�1>i.....Days Birth lace r ...1.1
Cause of Death e ..
Certificate was signed by ,rtrbl. „ . ,$1 M.D.
Address Ae_44,q4v+4...,a..Zt.0.;p;
Place of Burial (or Removal)......erket;-~....
(If body Is to be tempqqarjjly held, fill in spl+}ice later)
Cemetery l.T.. .ter..e 41.. .r Date of Burial — AA 19. ...
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to e, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbe and on the ba •s eof I 11E Y GRANT A PERMIT
to 7 .. j.' ' P
r� r (Na (Address)
the L.� ... .. to hold temporarily and � ��, ��, the body.
(Tin taker or person having charge of corpse) p / (Inter, remove,or Wise rwise d no of[state how])
Dated 9` 19..9 6— (Signed) 0,4.n... ....,r 't.... 1�:�, ......,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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