Leland, Edith Form VS.81. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 CERTIFI TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town / / Registered No... ..
`//j/ Village of
Dist. I\c�J�Rt/ Count Lv or . ' �
y ty i~ .. ,.e- ��
I pfP"street address)
. r
Name of eceased Vetera g -
/.) Single, married, widowed, 7,/ • veteran, give name f Wu)
Sex Color " imsor divorced (write a word) CA"' Date o ; a ,�• " 5"....19fr.
Age 10 Ye /. nths...l..,. ., ys B l% ` %�
Cause of Death.....&Aga.. .. ..i
Certificate was signed by.... „:. , / M.D.
Address.. ..s . .
Place of Burial I: v 1 � a —��
(If body is to be te.. .. 1�ly a in p •atsr)
Cemetery ,...4 ... . Date of Buri / 5 19.,
(If body is to be t .orarily held, n space later)
Thin Certificate of Death ntaining the above stated particulars, having been p ented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the,same for re 'stration, have r orded it in my Local Reco with the ve d Registered
Number, basis th EBY NT A PERMIT
to i... Na.,. t4
s ddres )
the ....to hold temporarily - d e body.
if ker or ._rsoa ha harge rpse) ove,or oth se e of(stat )
Dated' f. ' / 19... (Signed)
Local Registrar
. Permit is sufficient for the (2emoval (and Interment or Cremation) of a body to any part of the State ( ject to local
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