Burnham, James Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q"'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.__..t.5 Register
ed�NN
County - Date of Death C.�,.A'74- Iqa 0—
Tower,V3� � 2-1Z' -- - Sexf11 Age 2, __Yrs. Color t rtfei is ...
lagefer City r Mos.}
(Cross out names not applicable)
Cause of Death _ Zt ,_..9......
Place of Burial :J2Q.f Ceme- Date Burial - 1 14—
(or Removal) ---- -- tery r
A CERTIFICATE OF DEATH of l /7/4, De__f�1-_-��AG � /1�. . f_f /,,
(Give full name of deceased)
having been presented to me containing t ove stated particulars,and,after careful examination,
the same appearing to be COMPLETE, C ECT, AND SATISFACTORY AS REQUIRED BY
LAW,I have accepted the same for registration, have recorded it in my Local Record with
the ab stat RegisterN ber,and on the s' hereo ER GRANT A P RMIT
to n
(Name of Under ker) • ddress)
the ✓L�I�K _ to e body.
(Undertaker o on having age of corpse) (Inter,re ov , 'e ose of to how])
Dated y , V 'b 1914 (Signed) _-�--- -:-- -- __
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, r
the above Permit must be included in the Transit Permit.
5-27-15-25.000 f21-6893}