Doray, Joseph Form VS 61. 5-24-35-25,000 (17-8593)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dr 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, LEGI/BLY WRITTEN IN DURABLE BLACK INK.
Dist.No.P -(a» QReggistered No.
• Town
•
County_ »...»..»..... ».»»»»__» .»».»...Villa.ge»» » ���% _»»»».»»».» ».»»»»»_ »»�»»».
or City (If city,give street address)
Name of d- ease » »»»»»._ » .._ » »»» »....»..........»»» ...»»»_»»
i - ngle,married,widowed,
Se iif "A Color .. ... ....or divorced (write the word).» .t: » Date Death 1, _ 19J.1---
-'-------Age 2/ Year ,, onth r' - •ays / Birthplac _ .
Cause of Death.»»...... `'..�/ .'..., -i..ni��_>:..ri��."r, �c! .» » _— »» » --..4:_
Certificate was signed by.»». -�, .j —. IJ JP . »... »»... »»» . .»...»». M.D.
Address »» » . ,,'/ ., - . .. » »»....»»»».»
ili
Place of Burial (or Removal ‘."Aril-.at../r1!� .,%.- ., - ........»................ "»» ...... ...... »» .»»
(If body is to be temporarily held,fill in s er) /
J '' »
Cemetery »Date of Burial_-.....--../ //d `j`�
(If body is to be temporarily held,fill in space later)
J »»»••••--19» ...
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 hay ccepted the same for registration, have recorded it in my Local- ord with the above stated Registered Number,
and the basis th eon~ RE���� RANT A PERMIT Qf
/ (Name) OFcAddress>
the .»»» to hold tempura and» �. - -4 the body.
ertaber or p sory awing charge of rm r se dispose of[state�bOyel)
Date _»...»... Masi.. (Signed)_ - ...." �_ ,i ce
- Local Registrar
This Permit is sufficient 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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