White, Christopher Forst VSe61. 1.23-33-25,000(17.5154) v._ _ s
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W` 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.
Dist.No...4.. �..&,/ Registered No. _....
Town • —
County V/d-treL 2 . ,., Village.... � t
// or City (If city,give street address)
Name of deceased...- _...��,�...' ..
ingle,married,widowed, `
Sex� .....Color or divorced (write the word).eal-f-e(-44-ted& .......Date of Deat .. ..!n14-1---.6,.lj 19.4/2..
Age..........,f .%.......Years.........1 Months........1/ . . . .Da s Birthplaces.. 4z.,��.A a4'1..._.........:.....
Cause of Death C�A7l x� „.... .... .� _ ....
Certificate was signed by ." r..,..?. .. .............M.D.
Address _.. ... ............. /. .7'...._._.�.__
Place of Burial (or Removal). t. i Uc ar.7cr ! ., .; '
(If body is to be temporarily held,fill in space later) P ,
Date of Buri . --.1.,,.i......._. ..._..h 19., :
Cemetery._ ._.____._.............._...-....... -��-v-^.ems.-�� • .......:.......
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been p sented to me, after careful examina-
tion, 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 Ntunbei,
and on the basis thereof I HEREBY GRANT A PERMIT
� - e) .rr+ r (Address)
the...... .!'. ,� _ _ ... (/ to hold temporarily and.... 7. - . . .... _...._. .the body.
(Und aker or person having charge of cor se) (Inter remove,or otherwise pose tate how]).
Dated...... .... . ..—.,,tt.0 191 (Signed) , .?..: .. _:ll „
Local Registrar
This ermit is sufficient for the Removal (and Interment or Cremation) of a body to part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit ( No. 62) is required.
fora,vs.�- YORK STAVE DEF TM T OF I EAL.
OFFICIAL BURIAL (OR REMOVAL) FERMI'`
Ri This,Parini cad ha aiyned only by the Local ,' r (Deputy or subrettistrar} o€the Primary Registration District 6
V o ) in which tha death occurred aft th G and acceptance of a CORRECT ANI COMPLETE CEtR'T.! ' c
DEAA , Y WRITTEN IN DURABLE BLACK,IN C• Town
J 'Village �� `` "`
t. AtA r ��s�f� ». , A City " " ' ',1 f ii�
�Az,
�/ 'at city,give street address)/
aZred
�. 6� let• 'ed,wid red, O (If e j name of 'o r)
°� '` �'` i , z,(write the wort') 0/ a ,.Date A .. '.
�Age. = s.� .».. �.irthp r � ��- _� � � ..�
�0,
,...41110.
-v fr' 118si ` "" -"' i.:.. �� ; .���,�'s Y Y
.h ..{ if.`{\ M N!, n Itil+.' �yj��J I Date-0f• • 1�C.�W, ; Mom, - T: +�
(II "f d, l� *- ,;.. l .Y • f'• fin. ..iK�' �, ��+"A+.
q +• R. is D mining the above stated •particulars, having been presented to , titter i t �-'
.till" > -the'same;;appearin .to be COMPLETE, CORRECT, AND SATISFACTORY 'AS:REQUIRED BYy.T W�
ei peatte for . ti. . hay . - it in my Local a above
` me , N " ,$.j A PERMIT
aa•aa a••a •,.N, _ �._
thea,a ...to hold temporarsl k. +,
Dated tIIa �.. c i )', a(Sig�ned). .� :� ; ^, '
This Permit is'to eient for tha Rejmoval, and Interment a r.Cremation) of a Eked,' any pact of the 1r _ tom.local
cemetery or other raenlational.�treleaa fnmonal br eona,wnn asrrler_M.wk;.3. .alma A Tr.,.a Par...i! !VS lrfd_'d21'.'Miem"no.%