Kirkpatrick, Baby Girl Form VS No.61. 1-20-30-75.000(17-4382)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed onl*"by the Local Reg"istrsr(Deputy or Subregiatrar)of the PrbssarY Re t e
;Ion District(Town,Villa „or City)in which the death dixurred after the FILING and accepts of a t vx-
RECT AND COMPLETE CERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No..-...5_0.Q. Registered No
County War.teJ_. __.._.._. ate of Deat . ../ _-_I?2
Town,Vil- t-i ' le 4 ictis IF allS. S Age Yrs. ' Colon /-1.........»
laze,oraity -- :
,� (off Mos.)
(If usety,Siva street address)�`e'1#.�,1f C �J`
Cause of Death. V�--���t --��~._ �_ -�.._...s
Place of B or emoval) - .-1 -....
Cemetery _ - - _ Date o B ._.Z� ...../
7.
Certificate.of Dea11 of - »..-----
e full name of deceased)
having been tad to me con ' e above stated particulars an , after careful examination
the same ap • to be COMPLETE, RRECT, AND SATISFACTORY AS REQUIRED BY'
LAW, I h accepted the e f titration,have record it in my Local Record.with
the abo tad eh EBY A P
(N tta
.
s
the _ - - - -_to
( or vmg charge ) I other to how))
Dated__�j � (Sign Local Registrar
This P it is sufficient for the Removal (and I tion) of a body to any part of the
State (subject to local cemetery or*titer m er regulations), unless is y common carrier.in which case a
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