Weaver, Warren Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
CM-'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. 561 Register No
A
County _ _ Dat of Death 91-.
mil- %yip /
lags er City h a Se0 Age (ofa Yrs. Color.... - - - _-._.--
r Mos.)
(Cross out names not applicable) ,
Cause of Death
43,
Place of Burial Ceme- rtuv Date of B _...LIg1.-
(or Removal) " '"` tery ,
A CERTIFICATE OF DEA H of A -C!fts- _,%i"----
(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 above st ed Register Ny her, nd on the has' ereof I IRE GRANT A PERMIT
e..
IO
(Name of U derta - -'dress)
the -.e4a. - to _the body.
(Undertaker rson having cjlarge of copse) (Inter,r- .y' ,.• e dispose state how])
LT / '� /
Dated 191--"• (Signed)- •_I. -•••- 0-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), provided, that where removal is by common carrier,
the above Permit must be included in the Transit Permit.
5-27-15-25,000(21-6893)
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