Hogan, Margaret Y
Form vs.s;`. ' NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Towi
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE 0
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
Dist. No / County �� VeWTP
g / ,--/ " .-F�1�
/7or Ci (If city,give street address)
Name ofdeceased G(
//, Single, m rigid, widowed, �,J� 1/
17
Sex. Color h/ or divorced (write the word) Date of a h / 19.T...
Age iO Years — 1V the /a Days Birthplace.. t �)"''
-- Cause of Death... �1 . ... .............. ... ,,
Certificate was signed b ... � . .... .... /�;��^�"`� ti7 r
Address
Place of Burial (or Remoyel')/-y 7 c ''"1" ,} 1
(lf body is to be temporarily tye7q, in space later) .
r
Cemetery Date of urial 19Y,1 1
at body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars. having been prese ted to me, after careful exami
nation, the same appearing to be COMPLETE, CORRECT. AND SATISFACTORY AS REOCIRED BY LW'
I have accep d the same for registration, ave recorded it in my Local Re r with the ov ted Registerei
Number, a on the basis r I HE GRANT A PERMIT
to
(N
the rri�pp to hold temporarily a body
(t;•.ertaker or pn baying charg c pse) e, o berwise d tate bo
Dated r% 19. (Signed)
Local Registrar
Thi: Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subj t to lace
cemetery or other regulations). unless removal is by cr,mm..n crt..;... ... ...1.:..6 ....... a T......_:, p...._.:. ive NI... CON L. ___...__.r
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