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Eggleston, Virginia Form VS 61. 6.8-34-50,000 (17-7901) , NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT wr 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.ii .. L..._. Registered No '',,// ex "-,l Town W� County...-...-...1 .. - _.Vi aga.... �. . . .............................................. orb;ty If city,give street addne Name of deceased _.�vsL,1t, o' �'7 7„....,44124---- -I. ?. _ _ ..:.. 7 Single,married,widowed, -- - • Sex w••..... Color ..... or divorced (write tiie wor W.:._._._ ........ ate Dea iL a . ,rAg,a.,,A,..- Years .... .. Months_..-. --- .....Days Birthplace , Cause of Death .. _.W_ Certificate was signed by............--........... .... .. V• Address...........................— Place of Burial (or Removal). -t . G a wfaid241.f ... (If body is to be temporari held,611 in space later f --- Cemetery ._ _ .... _.:: _ Date of Burial.... _. 19 (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 Record with the above stated- tired Number, -' and e • ereoor r, I' GRANT A PERMI tkte, .it'«-_ { ._ 1' .to hold temporarily and ( ess) ........ .,..„,the body. ( ert ker r paring charge fog�nse) —'---( ate otherwise di of is w , Dated.... ..........19. Si ed ..... ................. _ :.. ( ) 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. y E..�Oi m 0•V 1 . en ..-, 1...40.* y g..z.44 . r . w 0 co a .. m m a) 0 m w m "y m w a4 yi m ..a 43R. 5.)= 0 ° ca O cd.., a) pGcd p0.40m a'0..COv.: O 0.... cd• si r0-cd0 0a) Ou .,,0-- i+•. g4•!! "�J It m ?.o.y - O c •g4.,•..^ 1 ... . r .ri -:m 6.:� . ., q A.'� O m .?4. ..-'" O R35 61 W N i� a a.ag�v ,,0 *z4.ale a• " a,pa�-� 4.$-+.�5% Po•sCp" 4) u3c= .voA' v 0 wv °-di� ,,a .' sib r. a oQ � tdy � ,, S„ ��r ii y a =p. y.r.y r p T Gki*' p >~ y m leX S .st O y Z' r 1 r 1?.G� �."t7=�} U yy tt C c� a--v bQ r'n +, i O O.t{ °•CtiaC ..... 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