Furguson, Frederick NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W This Permit can be signed only by the Local Registrar(Deputy or S egistrar)of the Primary Registra.
tion District(Town.Village or City)an which the death oocuared after the FILING and tance of a COR.
REcr AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE CK INK.
Dist Nc6 -QZ Regis ed No......�..................
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County. �.rpm_. Date of Death_ . Ig3..!
1la e Q . Sex A[ Age._ _ Yrs. Color_ L _ ..
flit.
.... r os.)
(If city,give street
Cause of.Death. - - — e--•1'-....._.:------- _. A�!r�__ _` ---
Place of Burl Removal) * _J " 1_. •__.
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Cemetery_.... _.._ _ � ate of Buria
Certificate of Death of.-_ -- ` -_..--_ --(Give _
full name of41.4e...04#1,g4,440/0/
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
LAW, I • ve accepted the • - for registration,have recorded it in my Local Record with
the abov- ted Regis • `! , ,and on the basis /• I H Y A PERMIT
44iir
the. ...! _.. to _ he ...
Dated.__i o ) (Inter i '•;• I�"
, Local 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 carrier,in which case a
Transit Permit(VS No.tt)is required.
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