Hubbell, Edueira 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
( BITTEN IN DURABLE BLACK INK.
Dist. No. lT/ Registered No.
Town
County T�.�t L ,...... . f
y (If city,
give street addres '
Namee of deceased x
Y�7�'/ t Q�e ..Single,mars(d, eth widowed, ` ,� /�
Se, . p. olor.. or divorced (write the word �Gt.C.0 Date Deat .l 19ei
__,,
Age „l Years ! Months —1 ^ Days I;i rth plac ........ . . .. .. . .r.. =- ..,
Cause of Death a,Cli.&
Certificate was signed by - 'll Ozv ---e-01-/ M.D.
Address _-- _1... GrrCtL G % ��Place of Burial (or I:ei val) c
(If body is to be temporarily held, 11 in space r)
Cemetery Date of Buria . w........ .3 19..2 ______
(If body is to he temporarily held,fill in space' r)
The Certificate of Death contai"ng the above stated partic ars, having been pr ented to me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ccepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and o the basis thereo I HEREBY fa•PQNERNIT
to /� , . . .. . 4—,-6.--- '(✓ ,
the ��(:vame) (Address)
to hold temporarily and the body.
dertaker or perso avi g charge ofreorge)--_ ,re ve,or otherwise dispose of[state how])
Dated 19..s17..-9 (Signed)
. i i i2 Local Registrar-"`'
Thrs Permit is sufficient for the Removal (and Interment or Cremation) of a 13..a to any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Pe!,.it (VS No. 62) is required.
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