Smith, Clifford i orm Is:, 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
14' 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 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered o 4
Dist. Nt . . 'Tc/w,r ////
�..Count}'.... vilLa e r CO
�or Cit (If city, g' treat address)
Name of deceased
/// Single, m ed, widowed, t/
Sex-.2. ......C�ii�,r/✓ �„F,r divoried (wit the word) Date of �. .../ 19.Y i
Age .4' / Ye; -S Months C Days Birthplace .. �` , 7.-i.
Cause of Death..
Certificate was signed o,' "7" 4- M.D.
Address
Place of Burial (or 1' oval )
(If body is to be tempo held‘ill ) ce later) �/
Cemetery .. . .. ............ ..�.!e<etl Date of ria ,,P ..4 — 19.Z�.
(If body Is-to he temporarily held. till in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the sa le appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accep the same r r ' 'on, ve recorded it in my Local c d with th bov stated Registered
Number, a n has' reo Y GRANT A PERMIT
to
ss .
the .. .. . to hold temporarily an ... . .... ...... the body.
(L'adert r or o h •ng charge o corpse) �(I r m or theise se o is D
Dated 19. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of 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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