Ferneld, Thelma 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 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.. ..4 0 i Regi tered No
County- � �/� ate of Death__l _ /Vil-
— gI
laegerre•City"- fgkeg5l. -- Sex-_. _ Age 2'- � rs.
(Cross out names not applic e) (Or V..}
Cause of Death-- •-_-
Place.of Burialllate of Burial__
(or Removal) '-
A CERTIFICATE OF DEATH of-_ .
ive ull 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,/a above stated � //edRegistered Number,and on 1 asis thereofHEREBY GRANT A PERMIT
(N of U r) (Ad
the---_ to___ ,��� the body.
(U ertaker or person havin charge of c se) (Inter ov or wise di s se of[state how])
_._ .Dated- 3- (Signed)(Signed)_____
Deal Registrar
his Permit is sufficient for the Removal (and Interment or Cre ion)of body to any part of the
State (ubject to local cemetery or other regulations), provided,that w re rem val is by common carrier,
the above Permit must be included in the Transit Permit.
138045-28,000(2148047)
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