Haight, Ralph NEW YORK STATE°bEPARTMENT OF HEALTH
OFFICIAL BU"R}AL (OR REMOVAL) PERMIT
earThis Permit can be signed only by the Local (Deputy or se___strata of the Primary Registra-
REMIin O the 1 after
F aeamtance
RECT AND CO RTFI�TE FD WRITTEN IN DURABLE BLACK INK.Dist No..
County_.. arren r Date of Death:. • 1 193.1
Town,Vil-City of.Giens_Fa —City-- , . .. _ O -.
(If city.give street,•• •
Cause of Death-._.. _. . ,Al ....1 1.. ..-
Place of B -••ov ) ,A - 1 _ _
Cemetery _. .-- _ of Burial l [ ...Igi
Certificate of Death o
-
( 've f canna )
having been presented to me containing the above stated particulars and after careful examination
the same appearing to .-COMPLETE, CORRECT, AND SATISI ACTTORY AS REQUIRED BY
, I have accep . the same for registration,-rave -.. •ed it in my Local Record with
tDhaet ed Nun the basis I H th . e • " - 9i wZX.--A---.-PERMIT
..
/ 4. an s f ;j )
/ ", 4th ....•
Y( o_ vine charge�) ) �r � l `
(Signed.. ' If # or .' i'Local Registiar
This Permit-is sufficient for the Removal (and Interment or Cremation) of a body to any pout of the
State (subject to local cemetery or other regulations),unless removal is by common carrier.in which case a
Transit Permit(VS No.W is required.
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