Weeks, Ruth corm IS.fit. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 1N DURABLE BLACK INK. Re istered No
Town
7.0„... ............(44e.„..,...t.
Dist. N ..� 1..<.County- � N. ,T;lldg
,�01:-City (If city, give street )
Name of deceased ... . . ./ .�-a=��,�Et.!`S.1
,,f Single, married, widowed, �" ' /
Sex. .. ..... ..l olor/K! or divorced (write the word) 22.2g 4 SG.C....Date of lea //'ems ,,/ 1
Age s f Fear ,;1�• the .i( Days Birthplace.. .•... . .�. . ... .. �� t
Cause of Death r �. � ��}}1� � `
Certificate was 'signed lw .�,�,�i�,...... .... M.D.
Address ���t:�uu
Place of Burial (or Rem ) 7/4—i..,ete4.--e .,
(If body is to be temporarily ]d 11 iff space la r)Cemetery n.,dr.... .. .,,r!.,:4-s (,lq., Date of al.. .. . .. 19.V..j
(If body is to be temporarily held.fill in space later)
The Certificate of Death containing the above stated particulars, having been presented t e, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same for registration, ave recorded it in my Local Ijecor with the above s ted Registered
Nuytt r, and on the Wis t r f,I Ii r to PERMIT u
to.. ..�.e Iy [y
(Address)
the to hold temporarily and the body.
nderta or peal having charge/1 c�rp_se) ,In • ove,or otherwise spose of[state how])
Dated. 19..l' (Signed) . ... f\t
/ O— ' _ Local Registrar
"hue Per is sufficient for the Removal (and Interment or rema'On) of a body to any part of the State (subject to local
cemetery or other regulations).unless removal is by common carrier, in hich case a Transit Permit (VS No. 62) is required.
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