Fish, Bertha Iona vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
xr 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— ..,..5—.
----7 i Village
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Dist. No.. ..Q./...County.....,4 - or City ---•;Z'-‘di-it.r.w.‘ C'-z-- -e-------
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7" (If city,give street address)
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Name of deceased Z..'...-.7--.2.1..-K.Z-l-7.-4.- Q( ---, ..,
„ .--.--2 "---- Veteran --z-e---,/
--/. 7 .,.. Single, married, widowed, 4 .
v , Of veteran, sive name of War)
Sex. rc,7 Color. or divorced (write the word)...cd..-4---<-- -4- Date of Deph., -L-,(' •Z' .7f 19"--.'.7
Age 7/ Years Monffi Days s
1 irth 2.place . ..,,car...a.a.,- .-. c.:.•1 . a--/-4,--1 .,
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Cause of Death 1,e:.. .-ia. 2.i.b.....4 re-w':kr:C. /
Certificate was signed by -. zdc. - 1,1-e-. . .t...c.a.,..07 ..--/.-a-t.-s M.D.
Address. _ _
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Place of Burial (or :e M 0 V a 1) '''. -11.4-(4.II ? .1:6, ....' •y..44.111'41,-, ( ''' "'":7
(If body is to be tempor 11 held511141 -acflater) , ,,/ / '
Cemetery -..-• ..., ??.:;-..,.-t-71.-:--..41..e....-a -4-":-.,i Date of Burial ...7,-./.
(If body is to be temporarily held,fl space 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number:7 op the basis thereof I HEREBY GRANT A PERMIT.
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to - ,e..1.444-.4.:.:.......................4:-..,:e..-'.41-..-4-.11.5:-......c.4.4„,..41.45.6* 4::....,:,.
the .--e-e..2.'...-4-:&--..:2 ..... an. ...e...r- to hold tempo 'and: .-.-..e..e.-,..- the body.
(Undertaker or person having charge of corpse) v (Inter, ov ziht.171- (fd:redredisgese)--.. /of/Wats bowl)
Dated ./ (- 19$.--x
• 7' (Signed - ‘-:-?..-
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremati" ) of a body to any past of the State ("abject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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