Brodie, Edwin NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sirThis Permit can be signed only by the Local Registrar(Deputy or Sub registrar)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 COMPLETE CERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No.-5.6.9.1 Registeredi-st�- No..._---..- .-.__._
County a rren _ Date of Death-_.c�.,t�QsI..a-�`._19.-.
To QC(!s Falls, N. Y. � _: Age 6 f Yrs. Color._f:LL:�
t •
lage,of ity (Or Mgs.)
(If city,give street address-.._-__Cause of Death- . ..�iellT - �_. ....- -----
Place of B • Removal). ,�ef2. r..L.e.LeL.I._-- _.._..--...-...-_--_--_.--^._�
Cemet ' Date of Burial_- .e . --19_--!'
•
Certificate of Death of _IdA,(/t.YL.. _ La___'—_...
(Give full name of deceased)
having belt presented to me containing the above stated particulars and, after careful examination
the same a•peanng to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW, I} eve accepted the same for registration,have recorded it in my,Local Record with
thew•f -stated Regi,t N ,an o the basis th i,•fI HEREBY A pERIvr
the_..... - - — _ -.to.Y _. ' . ---th- body.
( r er or person having charge of c) (In •••/L. •- ••.. °.of ,•w11
Dated.- .... L...__-.1 19.0 (Signed).- / / 1'j- .i�' ,
Local Regis
Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part the
subject to local cemetery or other regulations),unless removal is bycommon carrier,in which ease a
Transit Permit(VS No.62)is umpired.
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