Briggs, Irma Form VS. 61. 8-16-35-50,000 (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ifir 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 WRITTEN IN DURABLE BLACK INK.
Dist. No. S-6 a/ ��� /Registered No.
�j�/ Village `
Or Clty (If city, give scree address)
Name of deceased '�
4�t� Single arried, widwed, p- 3
Sex Color. or diva' ed (write the word) Date o��ii 19 6.
Age 3 Years .3 Months S- ays Birthplace.- Yt.Death lz...�.. ..a�'
Cause of Death....1.u. 4.r c1
Certificate was signed by - 0.��4 �� M.D.
Address ��.�..R..,r .... ✓ ��". :,/
Place of Burial (or Removals��zK.G+-� %'�"t'�! 4 1 i
(If body is to be to arily hel fill ' spat ter di-a-i--u.
/ifCemetery....�bi .�-�• Date of Burial • [!,/ - 19. .
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful examina-
tion, 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 stated Registered Number,
and o he basis thereofY GRANT A PERMIT /�to /-- 'e,A"-' c� /`2 "
(Name) (Address)
the to hold temporarily and the body.
(U er r or person having charge of core e) ( ove, otherwise ' ose of [state how])
Dated - ./U) 19.3.la (Signed) _. .
Local Registrar
This P it 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), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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