Jarvis, Carrie Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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. Registered No.
o • l
Dist. N �,Counttlf �r 7
•• Y Villillay
Village. ita
or City (If city, give street address)
Name of deceased ��'r I�Ldi Si „ •„
rngle, married, wid ed,
Se olor. divorced (writ(' the word) . ... ..ArG ..Date o th.. 1j ....19 r
Age Z1ath
gitter„.4Birthplace Cause •
Certificate was signed by M.D.
Address .. . . . .. .. . .... . .. . . .. . .. .
Place of Burial (or R moval).... aL_ >j .
(If body io Waltz, d,fill in spa lat )
Cemetery !//....ifempo Date o Burial.... i, 19
54-5
Of body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated parti ulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ccepted the same fo gistration, have recorded it in my Local Record with the above stated Registered
Num 'r, and on th }asis f I HEREBY GRANT A .PERMIT
to... .✓...•. ... me) ddrLvh i
the ` to hold teml-)racily nd athe body.
{U2 ertaker or pers having charge o c se) (Inter,r move,o rwi dispose of[stat how])
Dated. sy 19 (Sitncd` . /Ws_
cal egistrar
This Permit is sufficient for the Removal (and Interment +.,r Cremation f a body to any part of the State (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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