Rawlins, Bertha 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, LE- 7 �ijEN IN DURABLE BLACK INK.
Dist. No.... / gistered No.
Town
County -,-Village
01 (If city,give street addr
Name deceased .7 Cam../ L Gam' .� .C�-f.,_ !1/ .,-).4,�Q...? r-
, ingle,married,widowed, /I
Sex.r Color....���lt fear divorced (write the word),i � cam' Date of Dq.th:k .��. / 1-9 25-3 _
Age s..1 2 Years ✓ Months r J ^ Days Birthplace. . .. .. .. .. .. . .
Cause of Death At iiii � ' 41
Certificate was signed by ' �/.I/ al 4.... , M.D.
Address - .�1+
Place of Bt-' (or Removal) 1,r- -kt - `--c
(If body is to b tporarily el fill in,space later) ,{
Cemetery.. ..,.A Date of Burial 19 J
(If body is to 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 o e asis thereof 1;R BY t ' y T ERM
lc -g.A.,-f.A.„----°(C-C..,14-
Add
2-/-1-, '
'
ame) ( —
the /(/I /Y� '1'..r to hold temporarily a"d the body.
dertaker or person ving charge ofyrpfel (Inter,remove,or other ' i, ose o state how))
Dated... C. 19.... (Signed) 4 .....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) o 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 Tra sit Permit (VS No. 62) is required.
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