Nailor, Charles Form vs.es. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No�� Z
Village
Dist. No CQ'County....,• . . or City .��' . 4-7,- . .n74�e,:.(If city, give street address)
Name of deceased G ?e-a Veteran �—�
Single, married, widowed, ; 1 (If veteran. give na)ne of War)
Sex. `'.... ....Color �"/ or divorced (wnte the word)....A ...../..:..r't Date of D h i. 4 7� 19` x
Age /. Years.J,) Months ...Days Birthplace .2 z'--e---,--=`- fr.- L€E,. • '
Cause of Death .... b ra. —cr /
Certificate was signed by — .y `: v —rT. — M.D.
Address � , ! �_,.�r t,,. „_
Place of Burial (or Removal) .. ". /, l `l • --I.
(If body is to be tempora 1 held. *)Ora ce er) _' C/
Cemetery " :.:. .. %'�- ,-sz... a...s.., Date of Burial e 19. ./
(If body is to be temporarily held,dl apace later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accept the same for registration, have recorded it in my Local Record with the above stated Registered
Number, n th,basis thereof I-/,H,EREBY GRANT A PERMIT
to /.; fl rtl.:..!s.. .7` .��,e:.Y::�:-:Cht!(-(-ie.:4`. - t .t "< r�:...0).:tr` - _.._
L Winner — (Addressj
n:+.r:..z:u-tea--- to hold temp Sly and t...::,... -; the body.
(Undertaker or person having charge of corpse) (Inter,r ove, t se se of[stets how))
-Dated A`.,,...,‘ r, 19.:In. (Signed
� Local Registrar
This Permit is tinfficient for the Removal (and Interment or Cremati of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which ease a Transit Permit (VS No. 62) is required.
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