Coons, Millard Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
f '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.6__6 C 7 Registered No. / 6-
-County (kk‘4,/►,-A-e--v— ����Date of Death Y / 191.E
Town,Vi1- See. Age dniAr' - yy
lage, or City -' -- - g � �. Color_Vc.F�t.ds._---
G-Lv�,� ��.;-- UGC____, [ (Or Most q�
Gross out names not��+hca a D'
Cause of DeatIL.0 )
Place 6f'Buria eefue -'
(07 Removal) " gr- Date of Burial_ i91__6—
A CERTIFICATE OF DEA of_7 C&GI �.
(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
Niete At
(Name of Und Aker) ., (Address)
the__ �`rM�Y�-, f►-,--- c<^--- to y_ the body.
(Un ertaker or persoi hang chargebef corpse) (Inter,remo e,o thergr sq dis f[state how])
Dated igi.-is (Signed) --., �/'{ g
Local Registrar
is 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).
12.17-14-25,000 121-2566)