Bent, Susan I une IS.8I. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tyy 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. ' - _•ister No. / 7
Dist. No 7I f....County --V-iitage.// /7r—�.' ../ -f i 7 €€
) (If cite. give street address) •
Name of deceased t�City t�
Single, married, widowed,
Sex �!!',?.,...Color , or divorced (write the words Date of Death .. /./ 104.4
Age Sic Years Months 024 Days Birrthh lace , oe .. . . Xnx, �l
eri
Cause of Death -,e seer e� .4,/ �.-1-
Certificate was signed by /<5 !/ M.D.
Address 7 i.... ... .m
Place of Bu ((Jr Remov it) T sew4:.?. .z.e,,,,... ,,,47.. ,‘e.,:e...ra "7-6r--e-
(If body is to . porarily l 1?11 in space
Cemetery.. Date of Burial ,1111' ( ? 19.d
(If body is to be temporarily held. till in spa. later)
The Certificate of Death containing the above s ted particulars, having been present . to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATI FACTORY AS REQUIRED BY LAW,
I have a epted the same for registr. '.- have recorded it in my Lo ecord with the above stated Registered
Numb and on the asi ereof HER Y ANT A PERMIT
to. � Q
(Name) ( a ) I
the ® ) hold temporarily a the body.
(Und .er or perso acing charge of corpse) ,remove, r o r v disco [ tate howl)
p s
Dated , / 19.. /0-� (Signed)
Thi./�it is sufficient for the Removal r Local Registrar
(and Interment or Cremation) of a body to any part of the to (subject 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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