Ellsworth, George Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Regi Lion District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COM TE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town _. No.._.._..__-...._._
ittn
Dist. No.:J�°S 7...County Lc) avcru-� or e . j TC:Tt-T Y
5�
4 (I ° g 1street a.d es)'
Name of deceased.... ���'f...���k4r7.�L to -
Single, married, widowed, (If veteran, give name of Wu)
Sex .e.e- Color ki4.& or divorced (write the word) .ate of Death" -c- • - 19Age 0 '5 Years Months Dalace
Cause of Death. .. . U•^.,, °
Certificate was signed by M.D.
-
Address. 7-ief.-K-1-A-P--4
Place of Burial (or Removal .
(If body is to be temporarily held,fill In .ace la r)
Celiivtcl
9 Date of Burial .. . .... C� � 19 SI
(If body is to be temporarily held,flu In p e late
The Certificate of Death containin,, the -b ve stated particulars, having been presented to after careful exami-
nation, the same appearing to be IS u•LETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registr: 'on, have recorded it in my Lo I Record with the above stated Registered
Number, and .n the basis,h a EREBY GRANT A PERM -� w
to. srIt, �j
the / 'r ) (Add .�. .. „....c.
•••- ' `I.' to hold temporarily d :: :-:. the body.
(Undertaker r person having charge of orpse) �j Femme,or e4 is�yto how))
Dated C� � .1.7 i9.r .. (Signed) C.S�"... .... .�,� i%"r1P.h
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
. 6
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No ) is required. <
of
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axe liable VI Y ed' weal vi°1at.
T be enfor to repot
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�T2ie laW �der penalty