Prince, Ernede 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 FIL?NG and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. _3.2./2. . Registered No. /gr-1
Town
County Village
or City (If city,give tre address)
Name of deceased -�-2-c,-J.re. ....h.. ......�.--t... ' .,-Single,married,widowed,
Sex�n, Color or divorced (write the word) Date of D ath.. 1935—
Age / 02- Yea 1tlo hs l/ Days Birthplace
Cause of Death �� .... ...:F -e.--K
Certificate was signed by C^ -. .... .... .... ........ , M.D.
Address j�. L �... . .... ... l
Place of Burial (or Removal) .fie %'`15 ...4�!;/,'�`�i�
(If body is to be temporarily held,fill in space later) / / i
Cemetery Date of Burial Rr..A,_.,-' 6 19..a&
(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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on a basis thereof I ER Y T A PERMIT f�j,
to ...ed tfa',.1r•% ,.. , */ 44/ ' .c.r ,
�I e) dress)
the l4'.. .. L� to hold temporarily and w34, the body.
( ertaker or p having charge of corgi) (Inter,remove,or otherwise dispose of[state how])
Dated. ., 19.21. (Signed) .i.a.tvate P c;.7.,,s9pie-rynal
Local Ritifift4ar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to an 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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