Whitney, Lester Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
- This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District (Town,Village, or City) in which the death occurred after the FILING and acceptance of a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No.n6 6 6 ) Registered1 No ,
County C ` Date of Death_./ P er"1/. 5 I9 1-"
54-
Town,tail --,f/,.2 P
Iage, ety"" Sex Age___ Yrs. Color
r Mos.)
(Cross out names not agpble)
Cause of Death v-"'"
Place of Burial-- � Fa _ Ceme- _��,ri�{ Date of Burial."/tl� Z 191""Y
(or Removal) try 7�
A CERTIFICATE OF DEATH of �� �.- iii,"1.-1.037
(Give full name of deceas
having been presented to me containing the above stated particulars,and, after careful examination,
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 Registered Number,and on the basis thereof
II HEREBY GRANT A PERMIT
p I
(Name of Undertaker) (Address)
the e_..d : 9.-G�-�^— to -.11....{ the body.
(Under'l ak/er or person having charge of corpse) (Inter,r oyen,or/oj�h r se is ose of[state how])
Dated /J/�L_CC' G 191_y (Signed)""" ."-7.11
Loca 1 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), provided, that where removal is by common carrier,
the above Permit must be included in the official Transit Permit(Form VS No.62).