Chitty, Helen Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tom'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.--- ••• --
lS�o �. ... Registers$ Na
County _ -_ _ Date of Death (h/r a?✓er _19 .
Zbsysr,-�il- /
lash, or City - Sex (eAge_._._6 3 Yrs. Color
(Cross out names not applicable) /J (Or Mos.)
Cause of Death.._ ff"S%i a
Place_4.11 as'ai Ceme- = — -
(or Removal) tery "' o� Bu •
A CERTIFICATE OF DEAT of
(Givefu ame of deceased)
having been presented to me containing the above stated partic ars,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 a to Registered u r,and on the basis a eof I HER Y G A PERMIT
to .d
(Name of Undert ker (Address)
the _- to the body.
(UndertakeL2yRpion havi�ng, charge of co�(r se (Inter,remov , ispose of[st le how])
Dated - ¢ ._.7.1:_0_._19Ik. (Signed)-_
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crem ion)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 Transit Permit.
5-27-18-25,000(21-6883)