Bruso, Beatrice Form VS 61. 1-23-35-25,000(17-5154)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
OF' 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.. G / Registered No. `'S =2-
County._».C . Town»......._ Village. ._
or City » (If city,give street address)
Name of deceased.__. _....__._......_.....»
GSingle,married,widowed,
Sex.,' Z� Color._._.._. _.._.».or divorced(write the word) ......Date of Deat '', ., . 9. .t..
Age 7/Year _ Months ... Days Birthplac 7
Cause of Death__...._. _ . ._.„ ._ .._...»Certificate was signed by..__....� ... _ _ M.D.
Address. ...._..._........ ��Z
Place of Burial (or Removal)._. .. ��� __ ._._......_.... ...._..._......._.. _�_ _. ._.»__ __.
(If body is to be temporarily held,fill in space later) \
Cemetery . . Date of Burial 17 72.2.. ..... ... .... 19 ---s
(If body is to be temporarily held,fill in space Later)
The Certificate of Death containing the above stated particulars, having been presented to 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 Recordyuth the above stated Registered Number,
and on 1,th f I HEREBY GRANT A PERMIT
to— — - /- ...
e) (Address)
the—..._ .... _ » to hold tenipora 'y and.. . . __ » —..the body.
(Undert or n having charge of se.)- Inter, t erwise se of[state how]).
Dated ;` .» 19 (Signed
Local Registrar
This Permit is icient for the Removal (and Interment or Cremation) of a body to any part 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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