Shackett, Rose i arm % 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
kr 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 CERTIFICAI 01
//
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
—
�'OWiI�
Dist. No 4O 1.County... .. ....gilicx4ti Vikhge... ✓.... . . 111,044_,
.
Zy� City (If city, give street adh ss)
Nanie of deceased !t'.. .0t.R,
/ Single, married, widowed, ,/
Se:-. 4n .Co .,r�,h or c 'vorced (write the word Date of eath.. 'w 19 T;
.�geC�% ears l Days Birthplace. / .
l,aue of Death... ... _ . . . .......� .
Certificate was signed l,y W, W • M.D
Address .. . . . . ....7 ..a e€69 Yf_7
Place of Buri (or Removal)...7.��,,�i4J/e/�-,y�i� 944-4-
(If body le to b m ; i Id, lilt in space lad /�� w. . ��11
Cemetery .... .: . . 4-/'�rC.lsn Da of Burial a. 19. 4?
.(If body Is to be tempor rily held. fill in space later)
The - ificate of Death containing the above sta particulars, having been presented to me, after careful exami-
nat Il, tha same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hay. ac -pted the same for regis ion, have recorded it in my L. •': Record with the above stated Registered
Numbe ,�„dI on the • sis reo EREBY GRANT A PERMI 4., /x. /
e) ress)
the to hold tempora v and the body.
(Undert: r pets h: ng chargeof/corpse) ter,re ove, eradc/� pof[state how])
Dated 19...54S (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cr a • n o ody to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in hich cas a Transit Permit (VS No. 62) is required.
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