Shippee, Frances Form VS l6*.61. 1-24346 000(1r-110$)
'F NEW YORK STATE DEPARTMENT OF HEALTH
. OFFICIAL BURIAL (OR REMOVAL) PERMIT
l0iis ric Permit ca be n y)1T Dihee death
hI.occu errnly by the Local ed after eputy he INStaegiaG and 1110011_pelmets of mHRABi.6 INK)ef the Primer,S; '
Icon 71-This own V or C the dea the
ItECT AND a
Dist 1N - R.gi
County 1 p of Death.. - "
Town, :, r�
lege, e 4 Spy Age.torYrs. Color .
Cause of'' th--_.. - ae . N oa
Place of or..eta - r ,,,g.;.0.
Cemetery
. _ __-_-_-D of Burial.. _#' *°'
G cate of _
(Give full name of ) _
having been . -. to me containing the above stated parti•culars and after examination
the same .. . o be COMPLETE, CORRECT, AND SATISFACTORY ASREQUIRED $Y
I ha the awe`. registratin,have recorded it in my d arIth_
the �' ' ter ,and on the basis - -•. I HEREBhl:.:Ri'.11'
ty, ...,#2,4;#40.
rA.,,,,,,,,,,,„Air.
M �tO „ th- ..4.,.
vmg charge ) remove • a
Dated I 19_ im '`"' `` `#0"je7sae:--0 •
Local Registrar
T Permit 11 sufficient for the Removal(ancd Interment or Cremation) of a body to any part of the
State (su t to local cemetery_or.other regulations),.unless removal is by common carrier,in which case a