Burnham, Sarah E AIM
Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or'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.__47 R 0 Registered No
County Wiaa--2' '" ry Date9ff Death e--" _ /3 191 v~ -
Ta ,Vi1- iF � F� bSex_. _: Age 3 Yrs. Color � "loge,eYr" (Or Mos.)
(Cross out names not apphcabli
Cause of Death._.-___-_:__. _.-. �»� ' '' - ..,
Place of Burial Ceme-
(�++�._ll_ �f - ' _Date(or
j: G
(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 ab stated fie list ed Numb,----ea=on the basis thereof I HERE�B-Yr GRANT A RMI
to ii I. .r
sine of nde leer ` (Address)
the «" to _! the body.
(Und' aker or person having charge of corpse) (Inter,rem wise ' se of[stat
Dated 4-A-aL- t- ' i9i__t"" (Signed)___. __ . -•-
1. 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).
.n.w.I Se AIM ls1.2FM'l