Abare, Baby boy _vs.
Form VS.BI. NEW YORK STATE DEP41TMENT OF HEALTH
OFFICIAL BURIAL (OR. REMOVAL) PERMIT
02r 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 F OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. `..
/�/ Towni0eZ o
Dist. No4�.1.� County .. ... Villa.-
or City (If city, give street dress)
Name of deceased `...
.. . . .. ..
_• e, marri:., widowed, e ``
S ' •• . •• or ,r divorced ( • rite the word 0" , Date of e 1
Age . . on th . s ► ys OK/ '
Cause of Death / kii, /�� Birthplac
Certificate was signed by :..t. � .�Af!
M.D.
Address � ;.... ....-
Place of Burial (or Removal)
(IE body is to be tem r ?' held, fill a later),. ��V ��� l�Cemetery ., 2t�7. Da of Bu •/(j6l
(It body is to be-temporarily held, fill in space later) '
The Certificate of Death containing the above stated particulars, having been presented to me, alter 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 R d with th abov stated Registered
Numbed land :41.,a basis�� -r I HEREBY GRANT A PERP+/I '
the /.0: to hold temporarily an tie ,dy.
it
•maker or p a ham charge corpse) (I ov or otbe risyJish to ho ]
Dates /.. ... . . . .&I./6' 19 (Signed)... . .. .. .. . . .. . ....E.... ... .. .. .... ... ....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subjec 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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