Sansorisi, Chas Form VS 61. 5-24-35-25,000 (17-8593)
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, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No J - "l Registered No. .2- ‘ 7
Town �. ..
County 7Z--" Village
or City (If city,give street address)
Name of deceased.K....
��/ 3 „—
Sex married,widowed,
Sex Color.ei C or divorced (write the word) . �Y�� Dategeath ���� 19
Age / 0 Years Months Days Birthplace
Cause of Death _
-
Certificate was signed by 7) M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily held,fill in space later) rv(a
Cemetery Date of Burial l 2 19 3 5
(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 obasis_tlrereo HEREBY GRANT A PERMIT4//�AC�� G <�
to �..M»�
(Address)
the to hold temporarily and 4w.)' the body.
(Undertake or person having charge of corps (Inter, L, , erwisei,,sp��s of[state howl)
Dated G ,/..6 19 .l`7 (Signed) . ..AZ'uG'�"
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 No. 62) is required.
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