Eddy, Royal 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. 36 O Registered No.
County Date of Death____May
p ,Igi 4—
Town,ViI- h Sex__r .r. Age70 2 s. Color /�% G,=
lage,.or City ( os.)
(Cross out names not applicable)
Cause of Death
Place of Burial - _ Ce e- e
(or Removal) t r ate of Burial_.filav__y Igi A
A CERTIFICATE OF DEATH of 47
(GI ull name of deceased)
having been presented to me containing the abo stated p iculars,and,after careful examMlatiori,
the same appearing to be COMPLETE, CORRECT, AND ATISFACTORY AS REQUIRED BY
LAW,I have accepted the same for registration, have recorded it in my Local Recordco with
the above stated Registered Number,and on the • ereof I HEREBY�1 NTT A IT
to l/Li-- ,
(Name of ndert er �' �2� ddr-
the -...Le.�yi.__ _ _._ __ __ to
__: th body.
(Undertakglpt person having charge of corpse (Inter,r v r ' ose of Ista how])
Dated - _ .-_/-.d igi_ (Signed) ' --,... ---
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremate )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).
124744-25,000(21-2566)