Day, Esther I,.-"rat N 6i. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CERTIFICAT)OF
DEATH, LEGIBLYIB WRITTEN IN DURABLEUR BLACK INK. t Registered� � Q No. // '��
Dist. No.?..t1.(.1.County `'/1/.• ... ... .. . . ..'.. . .. .�K.....w�ii X144,..,�G�
er • or City (If city, trive street address) • /
Name of deceased.....• . ... ��.-
/�� single, married, owed, '/ /• pp
Se �eilc ur divorced (write the word' Date of D t .. ,. ./....19
Age �p 7...Years Months.... `
�,_.. Days Birthplace �.. .q,
Cause of Death �" •� r A
Certificate was signed . . . M.D.
1, fit
Address . . .''... • • If
Place of Buri- (or Removal j
ler
(If body is to b t porarily hell till In apace] r)
Cemetery.. ,r ,.,�. a(�� • Date of Burial .. ....da S 19.SesS
(If body Is to be temporarily held. sill 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 he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same for registration, have recorded it in my Local ecord with the above stated Registered
Number, d on the basi the-• . • _BY G• • NT A PERMI i..Attiet. Ora
the to hold temporaril and e body.
( ' a taker or person haying chargp�_o+f use) ( , e t is? state h
Dated.. ... ... 44.•/ 19..V (Signed).... .... . .. ... �... ..
This Permit is sufficient for the Removal Lan Registrar
(and Interment or Cremation) of a body to any y part of the State (su ect 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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