Clark, Ruth i 111 '.:, yI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re 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 CERTIF OF
DEATH, LEGIBLY WRITTE(V ABLE BLACK INK. Registered No �j
Tn,znl ^�
Dist. No UGC/ County �2�e.' /Ce/ V-i xge.. �'GG .. ..
/, z f Cl V (If ei . give street a re,-,)
Name of deceased \`��/{/'
T14 _, /,/` ,�,, Single, married, widowed, •
Sex.L 7-491LColur w�(.�r,r divorced (write the word). . . Date of De th. /J + ` �i � �(L11916.
..
Age " irs -- ontlis o2, Days Bir place.. ...,�!l`Z .. AGO ff .,.
Cause of Death. ,:�.a (/ -2
Certificate was signed by - .. ...T A, )
Address -rate tj `�/
Place of Burial (Rr Removal i... .... ... o �
(If body is to nporarilr held, till ins Iater ''//
Cemetery. . .. Date of Burial '2/ 19 14
(If body is to be temporarily held. till in apace later)
The Certificate of Death containing the ab e 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 cal ecord with the above stated Registered
Numb and.on the pads th HEREBY GRANT A PERM ,��'
to u/ G�
Address)�
the to hold temporari and... . : body.
(L�t 1e a�qr person having charge of .orps ) ( r move,or other dis [state hos
Dated ...+�' 19., (Signed).. .. .
Local Registrar
Thi Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subj • o local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is req red.
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