Smith, Frank aura,vo Plc.ea. a-a-aa-au.vuv %a.-vow,
. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar( ty or Subre istrar)of the Primary Registra-
tion District(Town Vie or City)in which the death after the FILING and acceptance of a COB.
RECT AND COMPLETE CERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No.__. B. Regi No..__ __._____.----
- T
County_- . u_Aron_ _ Date of Deat .� / 14 11,031
Town,VilCity of CI D5 F 1S __. a.
lags,o> City s / ./_. Age-- _- Yrs. Color--------------- .-_
(If city,give street a. 1 • os.)
Cause of Death-- _ ---
i
Place of Buriary Removal)._ _ ,.a -_-
_Cemeterp.__. ._. _ _ ---._:Date of Burial—All. r�r9 �
.0
ii
Certificate of Death of___._.__'_.i / __.._----------�_.__---
(Give fill name of deceased)
having been presented to me containing the above stated particulars, and after careful examination
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
I.AW have *mapa same for registration,have recorded it in my Local Record with
the • ve sta Re • Tr-• Number,and on the . . I H B T A PERMIT
.. - ...____, .._. (Address) ------ -,
- - 1 -to - _the N.
( or having Charge` `) (In - . •• t
Dated._ di! (S ed) �/�Y1'1' v-- -- �•• --•-----
.t,. • : Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the
State (subject to local cemetery or other regulations), unless removal is by common ca�rri r,in which case a
Transit Permit(VS No.62)is reauired-
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