Gates, Eliza Form VS.bL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
,Tar 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 CERTI 1 T OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.....(1........ ..,,, ,�j�
��/' Town diat&La �P �ier' I t/.
Dist. No.' �.D�...County..2t�/ GZ� -��'s'� Villa •
ge.
. . . ... �o or City (If city, give street addss)
Name of deceased... . . .... . .. ....(�...,...
,{� ',,,��DD Ingle, married, widowed,
Sex.l!'-1 !�'''�SE!Colo .. . . r divorced (write the word) Date of peath.... 4��.. .
Age ,1.. Y ars onths 6 Days place.. /.
Cause of Death.. . . . .. ...
Certificate was sig F� .. .. . M.D.Address.._i K aCX� . . .. '� � J/ � �����
Place of Burial (or .Removal).. ... . ,�(±ekt�L,.....kra,E�CL
(If body is to be tiviborartl fi' n s,ace ater)
Cemetery... .... . Date of Burial ... /% 19 4,4,1
(If body Is to be temporarily b d, till 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
Numb , and on the a ' �qf� I BY GRANT A PERMIT iz•M yr,
-N •
me) (Addre )
the .. ... .. to hold tempor ri y n .. . the body.
(Un,ertak."or person b ving charge of corpse) t , nov or rwis soose of to ow])
Dated I. 19..�f (Signed).. .. ..
OLocal egistrar
This Permit s sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( ect 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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