Suckwall, Sarah Form VS. 61. 8-16-35-50,000 (17-1423) Y
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT '
This 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 WRII1'lN IN DURABLE BLACK INK.
Dist. No. 3-6 0/ Registered o,. --'
,Town County L 1.. azv�-z- “ "village 1 r 'z ..... .... ... .
7,yam or City (If city, give street address)
Name of deceased
��Q ',/62C4/2ea' 0--
v�Single, married, widowed,
Sex Color VV L! or divorced (write the word) Date of th �!lt *�C 19.. 6
Age 0' 0 Years Months -l Days Birthplace ^
Cause of Death ��[`
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��G�' 'C'... .. ........ _.
Certificate was signed b� M.D.
Address -a (7....e........4.4 _.. eZ ed, �G��i
Place of Buria r Removal)....,:....
(If body is to bet p ra "ly held, fill in spec ter) / .G
Cemetery Date of Burial .1�./.1,1` - QVI9.
(If body is to bet porarily held, fill in space later)
The Certific of Death containing the above stated particulars, having been presented to me, after careful examina-
tion, the s e 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 a basis thereof I/HERE GRANT A PERMIT
t0 •
(N ddress)
the to hold tempor ily and the body.
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(Undert er person having charge of c s ) _ter, remove, o/ et rwi of [state ))
Dated ... Ll 1.9 (Signed),..... _ ... ...
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation o a ody to a part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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