West, Effie i«,rr, 51. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t4' 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 CERTIFI A E OF
DEATH, LEGIBLY WRITTE URABLE BLACK INK. Registered No.
Dist. No $ a( County. selaaK--d � �
'IlYlage....r��L�
// gz ��'� �" t City (If city, give street add ss)
Name of deceased
--' `� ,�Q�-/;S� ingle, / arried, widowed, �j
Sex't--!?77, Col,�r./C luAI)q- divorced (write the word) Date of eath.. , of o� 19..f5
Age & "- ir,.p i Monti s ( Days Bi lace. ..o( ,.
lZete
Cause of Deathl�"� '�' ^! . .... .. ..... e
Certificate was signed by 4� M.D.
Address t'„7 „
Place of Bur.-d (or Removes A' ^zy.,�
(If body is to I) to do rily held, in space ter) '�Cemetery.... ... . . • Date\of Burial /�IP' 7 19li�S
(If body is to be tempor ily held. ill in space later
The Certificate of eath containing the , hove stated particulars, having been presented to me, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have ccepted the same
S-for
�registration, have recorded it in my Loca Record with the above stat d Registered
Num r, and ba/ tV f�REBY GRANT A PERMIT t� �A-Cf
to. - Iva I
the to hold temporarily d the bo
( t. er or perr��yn haying charge,,99f ror se) e ' ose o how
Dated rc t... u[..9 19..'t. (Signed).... r o
This 'ermit is sufficient for the Removal Local Registrar
(and Interment or Cremation) of a body to any part of the State (subject o 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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