Davis, Thomas Form VS No.61 NEW YORK '
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. 4501 Registered No. LW 144
County :Date of Death_Zuni 16 191 5
Town,Vii- Saratoga rin s
Inge, or City $ Sex__. Age Or rM__Yrs. Color
(Cross out names not applicable) ( )
Cause of.Death Cf er ebral. hemArrhage
Place of Burial i�; gi�� _Ceme- B____Pa1i.ate of Burial.___ATUTIE---1S91---5
---- -(or Removal) tery
A CERTIFICATE OF DEATH of namts
(Mire Tull 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
Charles l_es E. B illard G1sns--_Falls
(Name of Undertaker) (Address)
the Undertaker to 0m1oY-11---and--.in ;T body.
(Undetlioaker or pe %having c e f corpse) (In ove,or otherwise di e o. e how]
Dated 1I1 1O 4-r 4.a. 1___- (Signed) _ _ __ ,,__ --Aiiii
Local Regist
This Permit is sufficient for the Removal (and Interme or Cre ation)of a body to an' We
State (subject to local cemetery or other regulations), provided, where removal is by common carrier,
the above Permit must be included in the official Transit Permit(Form VS No.62).