Westcott, Ellen i orn. .s.nl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Z 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 CERTIFIC TE Of
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. .Registered No. //
Town
Dist. N f..D, Count.. Village.... ,', +!� \G
(If city, give street address)
Name of deceased 2reic We jam
Q�
Single, married, widowed,
Sex? ?, ..Color r divorced (write the word) Date of De th /Age : :• 'Address
Cause oeathCertificavas rez_z .XJ l••�d
Place of Burial (or Removal) .. :44-4.) .��f
(If body is to . •y porarill• hel in space later)
Cemetery.... -LX-L ..hGl..e) ate of Burial .. VI19(iL
(If body Is to be temporarily held. fill in space later
The Certificate of Death containing the above state articulars. having been presented to me, after careful exami-
na i)n. -he same appearing to he COMPLETE, C RECT, AND SATISFACTORY AS REQUIRED BY LAW.
I h. e a,cepted the same for re_': -- ion, have r- orded it in my Local cord with theme above� stated Registered
Numb- .n d on e,-asis . �-EREBY '-ANT A PERMIT �`"q; '.o to
}
i Na�� ) / / ( areas)
th, A' to hold tempor y and the body.
(Under •k- o peca baying charge of copse Inter,remo rot t lis'ose of[s bowl)
Dated ��dd 19 (,L�j (Signed) r $6 !!
Local Registrar
This Per. is sufficient for the Removal (and Interment or Cr mat, o a to any part of the State (subject to local
cemetery or . .er regulations),unless removal is by common carrier, in ich case ransit Permit (VS No. 62) is required.
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