Crandall, Mary Form VS 61. 5.24-3 5-25,000 (17-8593)
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, L IBLY?gWRITTEN IN DURABLE BLACK INK.
Dist.No..- ..»..!5.
n / Registered N ff��
County »»» »Villa '/
/// ».... ..». »...» .... ...» (,l_�
�» \✓ f city street address)
Name of deceased
Single,mar ed,widowed, /�y� •
Sex . i. Color • or divorce (write he word). 7„l . .• ....Date Dea 4.I1 jj` �
Age (4.- Year ... f Months ,, Days Bi place „„,
Cause of Death _.
�:t: E:1
signe .... ».. » M.D/7• X/(or :et ova ».
(If body is be tetra:ily I. fill i s a later
Cemetery ,((j'J](' I Date of Burial M 19....
(If body is to be temporarily held,fill in space later)
The Certificate of Death c ntaining the above stated particulars, having been presented to e, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY A REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my,cal al Record with the above s ted Registered Number,
and o basis,ther f HERE ids RA A PERMIT g1c.
r
t0 (Name) ««» � :.»» »..»» AA
( ddress)
the to hold temporari y an »... ..,�...... e body.
ertaker or rsonn arge of co er,remo e,or ther is ose of[stat ow
Dated/0e Cr(pp ( gn ) �
ocal Registrar
This Permit sufficient for the Removal (and Interment or Cremation) of a body o any' of the State (subject to loc cemetery
or other regulatio s), unless removal is by common carrier, in which case a Transit Permit (V No. 62) is required. (I
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