Shaw, John k'urm %S.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tow
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFJ�� O
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ji gistered No
Dist. N -r7� �county Vafil i.4.
e",
o i (If city,give street address)
Name of deceased .
Ingle, married, widowed,
O ,[,�`
S olor. ... . r divorced (write thff wor ~ Date of I� t �..e !'pf
Age Years... . .. Months ..5.......Da.„,......"ys Birthplace.��c`'`""— 1 . -.y
. ... .
Cause of Death
.....474.Certificate was signed by ,,. • •. _ M T
Address e •
Place of B la] r Removal) f�'�-t-
(lf body is U bet -�� orarilp Tel n pace later)
Cemetery .... .4.4.1,,, ..4.„tApv Date of urial — 19
(If body is to be temporarily he , fill in space later)
The Certificate of Death containing the above stated particulars, having been present 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 registration, recorded it in my Local R ord with the above stated Registered
Number, and the basis thereoq NT A PERMIT
to
fa e
the �� ..to hold temporaril and ., the body
( .�r.ca++o ker or person ha charge p orpse) ter, r move,or other oose tate h )) •
Dated i.' 19, (Signed; . .
Local Registrar
This •ermit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ject to loca
cemetery or other regulations), unless removal is by common carrier_ ;n ..,h;r.6 r.m.e s T......* P...•..,.r !VC N. a91 .. ..e...,,..e,1
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