Bacon, Clifford Form VS 61. 5.24-35-25,000 (17.8593)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gerThis Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ��
Registered No.
Dist.No , .a •1 3-- Town
Village �
County _............ ....." m. "."_" :
or City (If cit ,give street address)
Name of deceased..... .. •• - .. „ --- „```
ingle,married,widowed,
Da f DeathA '2 < 19.1,61'
Sex es ••Color. �s ••or divorced (write the word) •••N ��% �
s Birthplace.._ ... "
Age Years ......_..Months ...",....Day -
.e. . ► £. .t_
Cause of Death.......................... r . _— M.D.
Certificate was signed by " "." µ'I" .."4 o M_µ
Address....._..... "...............^i.�^•••_"...� �,�Z. � e. "7• _"..._.................". •••••
Place of Burial (or Removal) a�6 / `y� o� Q j
(If body is to be tem rarilY held, 1 in a later) ,�'/z�2 �"""""""' Date of Burial 7 2eILv' %..••421,.y° 1""""•4
Cemetery ` 1� F�
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful examina-
tion, D
RY AS
BY LAW,
the same appearing to COMPLETE,
have recorded it in my LocalRecord with theabove stated d Registered Number,
have accepted the same for registration, �Q,�/ y
and on e basis thereof I HEREBY GRANT A PERMIT ) /_ 1� �7�� V� �• /�'�f,t.
„jam ,
-• (Address)
(Name) _ (, res C, the body.
th • .(Na r ....to hold temporarily an (Inter,remove,or otherwise dispose of[state howl)
dertaker or erson saving charge of corpse) „
1 c , ..19... ..:. (Signed)0.....r., `�1(�.. .. .
Dated »......... ... .. Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body o a p
of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit (V No. 62) is required.
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