Montgomery, Thomas rVrm Va 1\4..Vt. a'1r00'IO,IMI%Sl'•tOVV)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
RirThis 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 T CERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No.LL_ F � % Regi ,' 'Nov
County__._ . �• - // i�' D to of Death% day �.y�j�
Pown,-.City
'/" . `� �_��, Sey �4 Age--- Yrs. Color_L�LI-- caE.L'�
lage, jt.-
(If city,give street address) ` —
Cause of Death- __ . - ...._ . _-. _._.-_-__.-. _-_-..
Place of Burial(or Remov _�__.-..__-. ._ .- ---- -- -_-- __----
` Date of Burial ? /
Cemetery.—......._.---- w7lJl1 ,_. - - � " {-�'•-19J
R-�
Certificate of Death of___. -
(Give full of deceased)
having been presented to me containing the abo tated particulars and, after careful inationa,,
the same appearing to be COMPLETE, CORRE T, AND SATISFACTORY AS REQUIRED BY
LAW, I have accepted the same for registration,have recorded it in my Local Record with
the a o_ve stated Regis red , on the basis rev I HEREBY ,,;• A PERMIT
(Na US eer)
the _ -- - ___.. to...____ _._. _ the bed .
(Un or ha • charge c ) (In ve orot d of[ howD
Dated ��.__... ._ __19 (Signed)� .-- _-- --_
Registrar
This Permit is lufficient for the Removal (and Interment or Cre ion) of a body to any part of the
State (subject to local cemetery or other regulations), unless removal is by common carrier, in which case a
Transit Permit(VS No.62)is required.