Akins, William Form VS.cl.. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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.
Town 7..........w.we,--.4-7
Dist. No 51O 5?County c-t3 �v'z'�' ^� Village of (If city give street addres
Name of deceased LA,)..
p_ D mingle, married, widowed, ,/�
Sex"A olor ��r divorced (write the word) Date o Death..N'. . ' I 7 19 4 S
Age (A to Ye rs f Months i . ays Birthplace �...
Li
Cause of Death x - .cam
Certificate was signed bv.... .i 1/1D.
Address � ,---4" 41'`..�. ....�" -�...� � �` `�,'° --
Place of Burial (or Removal) '� Fears
(If body is to be temporarily beld,efill in ce laterl
Cemetery.. -� ' ` ' -'' .YP- %% / *N Date of Burial —4..< .?"'v 19
(If body is to be temporarily held, WI in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and cat a Oasis thereof I HEREBY GRANT A PERMI yd..e." -$ ,. ,
�'Na+pe) (A as)
the '' ... .fefeLet..,, to hold temporarily and... the body.
1($pbertaker or person having charge of corpse) I ,r ve otherwise dis•ios of[state how])
Dated., - /-- `-z-.V' 19.l..`7 (Signed)
—Local Registrar
This Permit is sufficient for the Removal (and Interment or Crem n of a y to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case,s Transit Permit (VS No. 62) is required.
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