Culligan, Baby boy I erm 1 N. Si. NEW YORK STATE DEPARTMENT OF HEALTH .b.
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tom• 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 CERTILICATE Of
DEATH, LEGIBLY WRITTEN ABLE BLACK INK. Ree iistered
Team. J�V�/Y • 7
Dist. No..., -.g County.... i vn 1
dr'City (If citT, rive street add ss)
Name of deceased
4b4e Single, married, widowed, -
Sex. Colo or divorced (write the word) Date of Death 40/' 1.
Age Year,, — 'Months Day irthplace v...:.. ..... 7"a .... .-.
Cause of Death.... �...
Certificate was signed by .... . ... .... ..., ,,.,,., M.D
•
Address
Place of Buria or Removal i .4:54;i.Ge! �. ..R
(If body Is to be emp , ily held. till in space late
Cemetery..... .. .. Date of Burial .. '3.4 19.04.5
(If body Is to b •, mporarily held, WI iu space ater)
The Certificate of Death containing the above state particulars, having been presen ed to me, after careful exami-
nation. the same appearing to he COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW.
I have a ted the same for r-gistration, have recorded it in my Lo 1 Record with the above stated Registered
Number and on tl sis th- 'eof I E,EBY GRANT A PERMIT —
to g ', ..,` d 7, .,....�1 •,
( / s)
the ' ' to hold temporarily n e body.
nder ffker or person a ig charge oPf orpse) o , e e di 1 e
Dated.... • • 19...44j.-- (Signed)
Local Registrar •
This :1/rmit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su )ec cal
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is equired.
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