Elms, Charles ForajtVS.EL-. NEW YORK STATE DEPARTMENT OF HEALTH -
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W 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 DU LE BLACK INK. Registered No. "-
Town
Dist. No. SRO/ County
e/e // te- (If tits,give street address)
Na of deceased //1Y�/
1441Spingle, married, widowed, ,k/Se Colorr divorced (write thsword Date of Death i��l/7l ( i�-� 19Y'�
Age....117. Years.... ..Le.... onths - D ys erj. Birthplace
Cause of Death
Certificate was signed b , M.D.
Address ., 0 ,.
Place of Burial (or Removal)
(If body is to orarily.held,93111n epees la
Cemetery ,r-4 .- r-C-r�'✓ Date of Burial �• , 191
_
(If body is to be temporarily held,fill 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 SATISFAUIORY AS REQUIRED BY LAW.
I have ac pted the same for registration, have recorded it in my Local Record with the above
stated Registered
09
Numbe,r and on „basis t•.- I RE: GRANT A PERMIT `.�� �=--`'`� V
A f.i3749
j77 (Address)
the to hold temporarily d.... the body.
n r er o person7ving charge corpse) ov r h w' os of[state how])
Dated 19.9. . .(3. (Signed)
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 ease a Transit Permit (VS No. 62) is required.
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