Barber, Herbert Form VS 61. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W.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.
Dist. No.....,_,3...i..L.a. Registered No ./1/`
Town
County Village --6.e,,,.:-
or City / (If city,giveAreet address)
Name of deceased `// v-� L - �. /c t_-mac/
Single,married,widowed,
Sex., Color - or divorced (write the word) Date Death 19.t'
Age 78 Years Months Li Days Birthplace.._. ..._ ,... 41-^ .:...:..4.,
Cause of_Death �r�. �s:�::, . 4rd.�. .xat j,C /
Certificate was signed by ... ... , M.D.
Address i_
Place of Burial (or Removal) .. Z-40-..r. N—
(If body is to be temporarily held,fill in space later) �{ Q�-- )
Cemetery Date of Burial..a73 �/ ! 19...6 �'"
(If body is to he temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented ,.o me, after careful examina-
tion, 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,
and on the basis thereof I, HRE ' G' r T A PERMIT
to -c`. �^-► `t' i', , , G6.... 642Q ,
(Name) (Addtess)
the .t.�.....r I to hold temporarily and j1-401"-t-17-4 f `-44- tee^ the body.
dertaker or person having charge of corpse) (Inter,remove,or�ot�herwise dispose of[state how]).
Dated I6 19 (Signed).. - cal
Local Re 's
This Permit is sufficient for the Removal (and Interment or Cremation) of�to any art of the State (subject 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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