Wood, Mattie Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
VF-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. 1�'��2'� Registered No. if 3-
County 1'!l_&��ztt.Cru,.. Date of Death__n_oPP• X Z 19146
Town,Vil- � � _4`4 / Sex tdefr�.Age S 2- Yrs. Color_,44,e 44. `
lage, or City' `— Or Mos.
(Cross out names not licabie) ( )
Cause of Death /y1-s s_
Place of Burial rvCeme-
/Date of Burial
(or Removal) " tery _ vLl_.14,4__19i_i,L.
A CERTIFICATE OF DEATH of
(Give full name of deceased)
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 abov/ie stated Registered Number,and on the basis thereof I E/REBY GRANT A PERMIT
to c ,� C. ' v�G �
_ '� eA i i.,,
(Name
ir Undertake) (Address)
the to SZ-' Aq# the body.
(Undertaker or person having charge of corpse) (Inter,rempwe,oygth dispose of[state how])
Dated___11..enr" 3-.E-t 191.G_4 (Signed) _` c_C1''
• Local Registrar
This Permit is sufficient for the Removal (and Interment or re tion) a body to any part of the
State (subject to local cemetery or other regulations), provided, that where re oval is by common carrier,
the above Permit must be included in the official Transit Permit(Form VS No.62).