Freeman, Mary A Form VS No.61 NEW YORK •
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL") PERMIT
(Er"This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tiop District (Town,Village,or City) in which the death occurred after the FILING and acceptance of aCOR-
RECT ANDJOMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist..Naq. , S _ Registered No
County__IrX -'.• Date of Death___ —V.2 Sr--a- 1911—
Town,Vil- Q .
lags'orktity--C === � `""" Seg- Age. 3 Yrs. Color...,? ef_�..
(Cross out names not applicable) tt77 . -.sp—�+ (Or Mos.)
•
Cause of Death. Q A' Ca— LI -' S. .....____.._.._.._...
Place of Burial - ._. r,__. ,-- -
xt_
_,.- (or Removal) `" tery a o ur _ s L_ l t._.1915.�*
A CERTIFICATE OF DEATH of_ C_k1..__ _ ,a
(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, Ive recorded it in my Local Record with
the abovastated-Registered-Number,and on the lusts thereof I HEREBY GRANT A Puma
tor_ . ,._ %4, ga.-ti..._ - _._.. . .._.1-._._.._._.
-(Name of Undertaker) ... .,,
s9 the N�,,,nt.��#.s,.,'��;�st.�t., to_..__ the body.
(Undertaker or person having charge of corpse) (Inter,remove or • ose of[state howl)
Dated h_itce::..2_-3-= _I9I S - (Signed)._ '--, ��"'''� —.
Local Registrar
This Permit is sufficient for the Removal (and Interment o Creme' n)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 Transit Permit.
R.29.ir..,25 060(21.88911