Brown, Angie 4 -- %
Form IS. fit. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tor 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 f Town
Dist. No . ..✓../....County , itra.ge
N. I (If city, give street address)
Name of deceased Est✓ ►- hic-!G"`...407; 60-- J1
Si e, married, widowed, �„n i S. l7 ,
Sex r . ,oloyr' n ivorced (write t e word) Date of each 19.�{..0
Age ►e Years I1 ntl)s l Days itth lace.. .... t. .. ....4....
Cause of Death
Certificate was signed by . ..-=!`h�'.. . ... ..� , ,¢ M.D.
Address _ �( '
Place of Burial (or Removal) /1' .7!!h't-
(If body is to be tempor held,till ace later GGL,
Cemetery Date of Burial Asa 19.. E
(If body 1s to be temporarily held. fill in s$Sace later)
The Certificate of Death containing the above stated p rticulars, 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 Record with the above stated Registered
N l er, and on thesis ereof I IlEiR BY GR NT A PER T _7�
etiga.., --2.e.ei_.
ress)
the ` /.... to hold temporary and. the body.
(L•. .erso having charge of corpse) nter, ove,or otherwise snow of[state how])
Dated l 19..44 (Signed)... `
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cr ation) a body to any part of the State (subject to local
eeanetery nr other revulatinns)_ unless removal is by common carrier. in which case a Transit Permit (VS No. 62) is required.
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