Gurnee, Baby boy Form Vs.ci. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT •
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 CERTIFFI T.ly OF
DEATH, LEGIBLY��! WRITTEN IN DURABLE LACK INK. Registered No../
Dist. No„f.(Q..�J.l.County /� ... :
r City (If city, give st eet a ldreSc)
Name of deceased 4,4f,
Sep!%1� /� D- c' ogle, married, wid ved, .
`tetAK�Pi•Colo ., ,.livorced (write the word).. Date of D h 1916(
Age Years. I Birthplace... �... y'
Cause of Death
Certificate was signet - e.... ,- . NLD.
Address
Place of Buri. (or Removal).
(If body is to .porarily held. Si! n space 1: j
II
Cemetery.... ' . ... • Date of Burial 6 19. 46
(If body Is to be temporarily held, till in s ce later) z
The Certificate of Death containing the above stated particulars, having been pr ..ented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT. AND SATISFACTORY AS REOU1RED BY LAW.
I have acce ted the same for regis•'ation, have recorded it in my Local ecord with the above stated Registered
Number /on the basis t ref HERE=Y/' • NT APERMIT
/
the . - - . . . i. . .. to hold temporarily d. body.
Undertaker or person having charge c i.�se) ve o rwi ..
sta ho
Dated... . - 6 19.. .'. (Signed)X
. . . .. . . .... .. .. . ..... ...
Local Registrar
s Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sub' ct to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is r uired.
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