Brown, Cynthia ��h111
Form VS No.61 NEW YORK STATE DEPARTMENT OF HEALTH ''.. t0ALBANY °4''40 OFFICIAL BURIAL (OR REMOVAL) PERMIT P?A
This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra- > ° tt
tion District (Town, Village, or City) in which the death occurred after the FILING and acceptance of aCOR- eo-eo..
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No.S S 2 Registered No._.5
County a7 -`^ Date of Death_.../f -a 7 L 191.t2-
Town,Vil- n Sex Age Yrs. Color
lage, or City (Or Mos.)
(Cross out names not applible)
Cause of Death_.�__�_f" �%� ,'1-�,�4 } /�7 `�`
Place of Burial Gr�vt i - Ceme-_-1 yi-_/. Date of Burial /.s/1 191_
(or Removal) - ter
A CERTIFICATE OF DEATH of a- "y"'
(Give 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 Registered Number,and on the basis thereof I HEREBY GRANT A PERMIT
to
�/(Name of Undertaker) a (Address)
the SfN- . - _144 -- to ./,a- the body.
(TJnqs,ct4er or perSl>n having charge of corpse) (Inter '1ve-O herw' i of[state how])
1 -� /�
Dated-..-� --�- — 19 LI (Signed) x�-�!"-' 7_,.--. -_ 4��t
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), provided, that where removal is by common carrier,
the above Permit must be included in the official Transit Permit(Form VS No.62).