Potter, Henritta torus VO NO.el. 6-Z-31-10,1/uv ud-.Jovw
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
i ii This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District(Town Village or City)in which the death occurred after the FILING and acceptance of a COR-
RECT AND C` .
_ P TE CO ERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No-4 - t.7_.. Registered No
County •,141..aet.t!ilrt___---.__....---- Date of Death .19. -�
Town,Vi � /�� i � �r�.
is e,or - Se'"e��Age..�_.e�a.-Yrs. Color__.�hetFa
$ V (OrMos.)
Cause o }
o ea `. _ .das� _ --•__
Place of Bottri '(or Removal) "4 r s&i.a_. -.'rta ---
f •
€emet,erY. -�L6,,.. .444ge_......................... Date of Burial #t 9=..
Fs1',
-.Certificate of Death,of.___ _ • nits=
( ive full name of deceased)
having been presented to me containing the above stated particulars and, after careful examination
the same appeto be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW, I have,acc.pted the same for registration,have recorded it in my Local Record with
the a ve stated Regil j Num/ber,and on the basis I Y GRANT A PERMIT
to-- .rr<At+f./r+ -tl..;/ J •�aTL.1ifer.C._ — -_ - , --�� � C� +st..--_. ;
' ( e ndertaker) ddress)
the to______-- - _ the body.
dertker or/person having charge of corpse) (Intihydnove oth- disposq of[state howl)
Date d► / rms..droest.•.i -1-`--•i9- (Signed)_ f
FL
t , • gistrar
T Permit isefsufiicient for`the Removal (and Interns Br �-%- - a body to any part of the
State (su ject to local cemetery or other regulations),unless remo.- r s by}• carrier,in which case a
Transit Permit(VS No.621 ismmuired.
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