Murray, Valney 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 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...F .s.,.. - Registered No..
County_ __.....__.._ .._._....._._. Date of Death...,..... .. .19.(
Town, Vil- ">
lage, or City � '�'`-'� Sex ....__ Age P ..___Yrs. Color....Xa!_..».
(If city give street address) 1 1 (F3r Jo,)os.
Cause of Death L.Gh }V\'& _....._
Place of Burial W � ttilI 1
or Removal). ._ _..._.._.... _. .......__._...."_...Date of t ial_.: ......_... j19..a.....
A CERTIFICATE OF DEATH of _ ..,.. —
(Gi e 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 above stated Register d umb�e and on the basi thereo HEREBY GRANT A PERMIT
11 to 1 NR>......_ V Y,I�Y. 1. ...4 n LA
Q (Namq of, ��ta i.. ( ddge�ss) :
the ......_.._. `-:..._. to ..__.. . .. __\:-.:.....Y..�..__.:._..._._.the body.
(Undertaker or ?Ton having charge of corpse) , (Inter, r��ove, or th min dispo yipmiyx ,
Dated 19... .c."i- (Signed)..1..tl.L L. __......_..._.._....._.._...._
�� 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 62) is required.
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