Conkilin, Baby boy *
Form MIL 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 Subr ■strar)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.y__6 ,2__y Registered N . q
County t it 1�---- J�Date of Death__ L // 1916
Town,Vil- �LT - d Sex_,bacAge Yrs. Color___L —
lege,or City f�� (Or Mos.)
(Cross out names not applicable) W
Cause.of Death //��,,,, /
Place of Burial Ceme- y_. _` .-Date of BuriaL_LLiutteh4 i9t A
(or Removal) tery
A CERTIFICATE OF DEATH of
(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 st ted Registered N ber and on the bssis thereof I HEREBY GRANT A PERMIT
(Name of Undertaker) (Address)
the to._______--/ the body.
(Undertaker or person having charge of corpse) (In r-.. o oth e di [state how))
Dated I91---- , (Sign'. - ---- -- -d--L..--------
Local Registrar
This Permit is sufficient for the Removal(and ter nt or Cremation)of a body to any part of the
State (subject to local cemetery or other regulations) pro ded,that where removal is by common carrier,
the above Permit must be included in the official Tran t%-rmit(Form VS No.62).