Sansouci, Margaret I-..r,„ IN.til. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t4 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 CERTIF pATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Register No.... (0 L!
Dist. NcC- °� County ��/) � / l
^�5 or (If city. Rice str, address)
Name of deceased
Single, ma d, widowed, ��
Sex Color or gvorce (write the word) Date of eath /e19.,``T.,
Age 7,0 Yea Mon s / „Days Birthpla
Cause of Death !/ ' ..' • -... r
Certificate was signed by. ... . •...' - .. . . ....< ..fly..,.... M.D.
Address �. ."7l��. ...
/
Place of Burial (or R/o all. ..%' ? ....<, - -.
(If body is to be teuiporari,• %j, t zrc o, • �� / / t tt�l�(
Cemetery it ��� . ... � Date of B rial 19.1`"
(If hotly Is to be to •.or: ily field. till tliace later) -
The Certificate of Death con,fining the above stated particulars. having been presented to , after careful exami-
nation. th me appearing- o be OMPLE E, CORRECT, AND SATISFACTORY AS EQUIRED BY LAW.
I have a pted the same fo r 'stration, ecorded it in my Local R r 'th the abo to Registered
Number, on the ba 's f I H ANT A PERMIT
to
the to hold temporari t ody.
(., • r or perso Laving cLarg pee) I v o t erw disp eta how
Dated......... . . (I� / 19.. .. (Signed).. .. . . ....... . . ... .. . ....
Local Registrar
This Permit is s fficient for the Removal (and Interment or Cremation) of a body
to any part of the State (subjec to local
cemetery or other r lations),unless oval is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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