Sandine, Alice 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 Subr istrar)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 COMPLOTE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No. _6_S_-7 ' Registered No. 3 V
County Ql_iei4_i—, Date of Death...-- / 2 191__ '---
Town,Vil- Sex Age Li' Yrs. Color_-Q1/
lage, or City'-- -- - -
(Cross out names not�pp''cable) ` (Or Mos.)
Cause of Death___Llh.--x ,,lr_ c, ,� 1tLel 44, 4 1.'t„�_1.1, -lk
Place of Burial Ceme- �J
for Removal) tery l Date of Burial- - --_ -. __y..i91_6..—
A - IrIGATE OF ATH of .. Gi-_In..r
(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 abovvee stated/'e Registered Number,and o /the basis thereof I HEREBY GRANT A PERMIT
to__(6‘._`t_,.-_Se�•.44�(te-t_ ,. '� �Y+-t ,'
_ ,( aN.4o�f- -ct er) . (A ress)
the <ll�• T`r to the body.
(Unde ker son'having charge of corpse) (Inter,1.7)7,o other ' e i e o.f[state how])
Dated--- a ..) 191_ - (Signed) -`
1 Local Registrar
This 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). propided, 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(21-2566)