Jones, William F, .51. r NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tgr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No
• Town n i.r-
Dist. No-S���..�..�.Count�-�f. Vi�gx...Q
', / , r • r y (If city, give street ddress)
Name of deceased cif/. Lr7/I�A
ex ti eingle, married, widowed, ',/ /f
Sex. .... . ..Cohn. . . it divorced (write the word)./.1, ?7�11 d� Date of Death. /r- 19..i4!1
Age 1O Years . .Months • / Days Birthplaces /. 74/ •
Cause of Death u-`t ��ZG—! .a�-a-►�. C%
Certificate was signed by....F �f-f!F.. . . ms .. � M.D.
Address G�°�w
Place of Puri (),1-,Removal) ?—F.6..' ...,(7. ..... . .
(If body Is to be to porarily held-4n1 In space la r �J
Cemetery .. ..'. �� � Date of Buria c 19.ila
(If body is to be temporarily held.fill In space later)
The Certificate of Death containing the abov stated particulars, having been presented to me, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same f r registration, have recorded it in my Local Record with the above stated Registered
Nu a and on the basis hereof I HEREBY GRANT A PERMIT
to e.... . �d-!s.Grt-4_ '�. 't, G -� sue. ���z'/
)
th .. ... ... .� (Nam to hold temporarily and (Address) the body.
( Berta ter or person having charge of rpse) me e ove,or otherwise dispose of[state how])
Dated �......, ( 19.M.cJ. (Signed)....
Local Registrar
This Permit is sufficient for the Removal (and Interment or r atio of a body to any part of the State (subject to local
cemetery or other regulations).unless removal is by common carrier,in ich case a Transit Permit (VS No. 62) is required.
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