Smith, Baby girl Form VS 61. 6-8-34.50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
'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. J_ ' c Registered o `0 7
Town
County i'��. /fi* / Vill .. .. .. . �.....
e`y , or ..y%y • (If city,give street address)
Name of eceased
. Single, arried,widowed, ,
Sex • ...Color .. ... . ..or div ced (write the word)... Date ath . .. ...a9..t 19..:...5
Age.... . Bir ce G G�.
Cause of Death .� - -{.f 1.. ... .. WO • .
Certificate was signed b , ..,>/ /7/ ' , M.D. '
Address tlf. ...,,�1�<
Place of Bur' Re al) .. '... . . .... .. D-� .... ... .... .,.
If bodyis to be .- ily held, in ater D ' �j
Cemetery .. .�� %lj? � � � r '/ Date of Burial —.�.:.. `)/' cP7 19.2.i5
(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 acc ted the same for re 'stration ave recorded it in my Local Record with the above stated Registered Number,
and o t e basis the o I H BY G TAPE MIT
the to hold temporarily nd th
' e body.
• X ker or perso lug charge or c: r,remove,or otherwise dispose of[state how]).
Dated ll 19. .. (Signed)... ... .......
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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