Nailor, Hughey l or°: 1 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t5 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 COMPLETEe CERTIFJCCI Of
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No //.5
Dist. No ��°) County � C.L.-4er-- ALge4 /!.�•te��
#4,... :
A47,5
A.,,,"
r City (If city, give street address)
Name of deceased
/ ' ` Sing1 , mar Ied, widowed, .
Sex Color CA./ or divorce (write, the word) Date of ath....--V117,1"/ 19.
Age ,,1 Years.......T.... Month 0 Days Birthplace
Cause of Death ' .....
Certificate was signed by ..... .... ....... . .• ..:...#... s M.D
Address 1.
Place of Burial (,'�'emo -- ).
(If body is to be te� rily h d I a at r)
Cemetery.... . ..... .. . .. Date of B ial ....(, 7 19.
(If body is-to e temporarily field. hi n apace later)
The Certificate of Death co taining the , hove stated particulars. having been presented to e, after careful exami-
nation, the sam ,pearing to he CO. LETE, CO RECT, AND SATISFACTORY AS REQUIR I BY LAW.
I have accepte e same for re 's r on, have r it in my Local Rec. .. t". the above 'to• : ',rj red
Number, and e basis th I EREBY T A PERMIT /�� / /'/�' ,
.. .. .tO
e .. I "j'.do ::) 4
the to hold temporarily'a . ,"' ' ,•• i /e body.
(L r r person 7tprg8pefji .v• :rot.erw'�.>dis [a : )Dated 9. (Signed) ro . ( ... . ilI .... ...c
oc:1 Registrar F.
This Permit is suffi t for the Removal (and Interment or Cremation) of a body to any part of the State (s ject to local
cemetery or other regu`tio s),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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