Bovair, Daphne Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
iA=--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.._.s'f fix_Q_/ Registered No
County 41-4 Jj' Date of Death____ O'(l
1 er City
(Or os.)
-` _a! S ?.�__ Age Yrs. Color-__ �1U(Cross out names not applicable) D
Cause of Death L/
Place of Burial �/ ��/`
(or Removal) - Cery I' \ Date of urial_C lf!lClf 9r
' A CERTIFICATE OF D ATH of________/il' 73.
-
having been presented to me containing the ab veve stated pive artil culars,and deceased)e of aftecareful the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIREDtBY
LAW, I have accepted the same for registration, have recorded it in my Local Record with
the above state Registered
Registered umber,and on the basis the of I HERE GR T A PERMIT
to P�p
2/7
(Name of Und taker (Add ss)
the , . - taker
LPn to
m re
(Undert erson havin ch rge of corpse) (Inter, the body.
Dated _ t^ er dispose of tat,how])
-,- �— _ 1915.1 (Signed)_ ---�---
Local Regi
This Permit is sufficient for the Removal (and Interment or Creihation)of a body to yan r
State (subject to local cemetery or other regulations), provided,that where removal is y common carrier,
the above Permit must be included in the Transit Permit.
6-27-13-25,000(21-6893)