Brunszisk, Stephanie Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1C'This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the-Primary Registra-
tion District (Tgwn,Village, or City) in which the death occurred after the FILING and acceptance of a COR-
RECT AND CO LETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No._ . `s` Registered No 1,�,Y_County .--s-fir Date of Death__ 2__3 191_$-
Town,Vil- /- ,
1age, or City ya`^ S24 4c Age e _.Yrs. Color_ eA
(Cross out names no+�,�pplic ble) �] / r Mos.)� .
Cause of Death..[1_ _. 4 s. AFC M cte 1.... _ C gs.„l�.r
Place of Burial 1'-�.�.. d .c ter e (/
(or RernovaTj tr's .. Date of Buri6,1 Z_ ___Igi_-1—
A CERTIFICATE OF DEATH of_ _,eC�i _ i , 0� _-
/ (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
e of/Undertaker (Address)
the cu-,d(ct- to . -s..= the body.
(Un rtaker or person having chaisge.of corpse) (Inter,r o ,orr herwis e f[state how])
Dated__-- ..2,..i gi_S_' (Signed) 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).
12.17-14-25,000(21-2566)