Duell, Ella Form VS No.61. 1-20-30-75,000(17-4362)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ggrThis 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 ANDGOil PIjL ERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No. Registered Na -
County _ . Date of Death../-- a 19-
Town,Vi1-�� __ Sea Age__jc�T___ . Color_-..G.�'
(age,or City' "- ' �� M
(If city,give street address) _. (�' os.) t
Cause of Death _._.--- =ts ,ks.... a.-----
Place of Burial(or Removal._, w__.__ .--z.�s.�j ..
•
Cemetery---_._----_----------- - 5`---- =- ---Date urial_. -= 69.
-Certificate of Death of Seelr...
(Give full name of decra.rd)
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 t e for registration,have r rd it in my Local d 'titthe abov sta egist- . ber he basis th EREB A P IT
(Na of ' r (Ad
the , � to - - __the body.
(Underta]er or per_ h ng corpse) (In .ve er of[state howl)
��.1ifi Local Registrar
This P it is sufficient for the Removal (and IntermentPort ofState (subjec to local cemetery or other regulatiaas),unless , •pal is by common a....le.,in which cam
T...w-:s W :f_NC Pao. Coil:2 W..i—.:
vs
- v
Ili I a 0t
,ttis•vrri,v4 tot 01 - 'lc 1 1 0%
tt.15,-5 I
Atho 9.,-... " om 0. af.a
tovv, i...‘„,..,i,..%vet % o , le .rA 0 iTa
TV °Aar ls Tto:t'9;', t091.-s 3) -6
no iiticAVtift9:a te livigog9-sittir-15.0 .0 tvi at . 0%94
ts. A -atelo. is slisiix...I iA tit% YlAtl,.%?.. ° ill °I; ‘I 1 s\ Vs
tztlie iht el Vt0,4 oevily.III rot"4 s%I 1 i .. ., \ tp totA
Wat% ViAtti ers-g. toql iitiiif. if,". td v4-"a' - ' ga\ OCI
•lvi°,7, tt-e_w-t. AI-0'11 Vg• tit0 It.I 2 .v10.9.1977,f1:e 4 fetr 1 e VI ,Ci VI
*.111. OW3- tvitA ' ti 0,1:4431.r, Vitia-"Visv %;-2-1 gltit4%.t .0.1• % el:: 0 A 0
Vst Att 1 A vc.1.,1 gtgV:s 4 ,gtt°,14-aVe t.3tIg I . —\ %ia 0
1
1.4 ttras ..t itt.;. 1 u• 1-4- /-%s im.• try a tl, \
St4 tiA ItitAvh• Atot a. -=...A.c.A , ,...:‘,.i, : \ t4 C441
\
‘1%\t%515ilte-93.16:el lit 151tVatt ratrYl.rl "V"5 %.-0 \ 1 It la%
tttt Ve. IP) to :OA$4 %.0 5t 73, • %V? 1j 1 \ \ t4 vd IA,
‘
.Ifj" 4'tit%Art S.4.;S gl 1 5et ttn IX.S'i ‘1%t t \ 1. %
II S
V% 41t I All g i 0_%..0 cetAA Ototli" 104 Net V 4 Still%'' \
Iititl 541.1111:;5112•41-1f: V9571*.1 ArliAt‘lit% AO
4 r ti.;t5t%%vs.:0;85Si ,x, ft„0 II Ittla
it VI r=%‘Vs‘ttus %..A t4 ts 4 t3
- 1 TV t-irsiVti;0 %%WWI
silas 1 At iUttva ?t
tigi $115