Conklin, John 41
Form VS No.61 NEW YORK
STATE DEPARTMENT OF IfirOLTH 44, ,
ALBANY f 'ta
OFFICIAL BURIAL (OR REMOVAL) PERMIT 'k
( 'This Permit can be signed only by the Local Registrar(Deputy or Subregggstrar)of the Primary Registra-
tion District (To Village,or City) in which the death occurred after the FILING and acceptance of aCOR
RECT AND C ETf RTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE--BLACK'II'iIC.
Dist.No. - Re • red o.
County ~` C G�s of Death
Teener-rile GI
.le-•er•City - - Age' Yrs. Colo _ .
(Cross-out names not a li ble (OrtMo )
Cause of Death Place of Burial m , air...ate of a i i
(or Removal) to ' 9
A CERTIFICATE OF DEATH of
(Give full name of deceased)
having been presented to me containing above stated particulars,and,after careful examination,
the same appearing to be COMPLETE, ECT, 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 the basis thereof I HEREBY GRANT A PERMIT
to f a
(Name of Undertaker) rli -• -- ,
the y to �'% ' � _ t
(Und son♦ 'ig charge of eq/pse) (Int r o ,or,'e 'spose o y
Dated igi_.. (Signed).._. 4 ' •
Local R strar
This Permit is sufficient for the Removal (and Intern: t 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 c ' ,
the above Permit must be included in the Transit Permit.
12 045 25,000(2143017)
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