Washburn, Charles .I<'orpa Vs.tii. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
V 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. egistered No.
// ,,��../I /' r.,,, Townei:)...,,
Dist. No�tQ.t��County �'4�/ v 'S ridge,..
//jj� � nn (I _it , ,rive stye addre,i
Name of deceased - ... ... .���(.l(�WC S!!..
Single, married, widowed, ��/ �/J�
Se. .. ... Color.h or divorced (write the word) .• 6 Date of Death.. `� 1°
Age... .2 Years / Y hi, Days ,iy� Birthplace
u /yr7�CeTel C.l'
Cause of Death . .. .. .. -• � et
Certificate was signed by `AV
l:.. 711 • M.D.
Address _ � . . . ... ... Pi '
l �=;ti of Bunal (or k�cnu,val i _
!if body is to be Wily h d, tii a ce later) /� ��'' y� ,) ,
Cemetery A� `// ate of Burial f•F-••{ ... t2( 19..iej
(lr body is�to be temporarily held. till 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 he COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW.
I have acce ted the same f„r r gistration, .ve recorded it in my Local Record with the above st• • d Registered
i.9
Numb d o .asis - • • "E%:Y GRANT A PERMIT „,
to •
tl)t— �'rI� ` ( Iress
to hold temporarily an the(iodv.
f, - ,er ••ker or person b -i " charge of k'oy,use) ter, rein ,o /t} rwi e is •lose of [s to how])
/ l0.. .t,,l I. ,fried! .. ... .. ......- .. .!. .
... .. .. .. ..
ocal Registrar
1-iais Permit i ufficient for the Removal (and Interment or a ) o a ody to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in ich ca a Transit Permit (VS No. 62) is required.
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