White, Julie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Lir 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.
S .-
u Lila, Town, Vill , "� is /�Dist. No.., ? .- ( Cou ty _ or City.... ...............
/L./
(If city give street a ress)
Name of d eOsed ° Veteran C/
��' �_ L (If veteran, give name of War)
Single, married, widowed,
...Sex or divorced (write the word) .. .a''U Date of Death / _ 19 .?t ..
Age... Y- • Mo s Day Birthplace ''? `
Caus of Death �n v '"
Certificate was signe, b ... /..... M.D.
Addres / /l / ,
,� ......
Place ofBurial�m•emoval - ,,f
(If body is to be. re .orartly he el Cill in • a e later
Cemetery (./ :' .. Date of Burial 1��
(If body is to he temporarily held n space lacer
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same a,p ring to be COMPLETE, CORRECT, AND SATISFACTORY AS RE IRED BY LAW, I have accepted the same for registra-
tion aver corded it • y Local Record with the above stated Register d umber, and igbasis hereof I HEREBY GRANT A
PE MI
to 1L
(Name) (Address)
the to hold temporarily and the body
(Underta er o person having charge of arse) ( r, remove, or otherwise dispose of (state how))
Dated / 6 1 V (Signed)
7Lo a gi •
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t any part of theState ject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
FOlt:Vc VS. 61. (1114:V. 6/63) (A2-248)