Irish, Warren Form` il. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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.ICA OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. p( 7
4.9 /'/ Town !!
Dist. No County...hf� ti illage. . .. ..... . ... . ... .
• or City (I city, give street address
Name of deceased. . ...
�� Single, married, widowed,
Sex.. . . _... Co1orL' <>i- divorced (write the word) Date of Death .. ...iizzr... 19��
Age Y rs g � Mo the .. Days Birthplace...
Cause of Death.... .. . .. .... . .
Certificate was sig by... ... . M.D.
Address... . , . . .... ......
Place of Burial (or Removal)... ... ... ... ~if .. . .... ..
(If body la to b?sspaporarily}ei 11 in space
Cemetery....U`".. L-Q r/... Date of Burial ,..,./r 19. ...tf
(If body Is to be temporarily held, iiii 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 REQLIRELD BY LAW.
I have accepted the same for registration have recorded it in my Local Record the above stated Registered
Numb and on i., .as.,, -,,Ij' BY GRANT A PERMI
to.. . ' ..(y.1.. r;dsRy� /... -' .
/ U. •r-• r •
as)
the - ' ArArr/. /;1.. to hold t orar. and the body.
( to: ,_ or pyzioi having charg o as$se) r, rem ve,o o erwise o e of(state how
Date. s� i il - .1 19� (Signed)
Local Registrar
This P mit is sufficient for the Removal (and Interment or emation of a y to any part of the State (subject to local
cemetery or other regulations), unless removal is by common can r, in which cas a Transit Permit (VS No. 62) is required.
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