Shippey, Elfreida Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1P'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 aCOR.
RECT AND COMP CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No..0,',` Regis red No
'fA
County � ate of Death 3 — 91_
} C t� �'�- — ... Sex...21. Age 1 _ rs. Color-.'
(Cross out names not applicable) ("'
Cause of Death.__ -~
Place of Burial r��,6.(�.Q..- Ceme- e,. Bu sZJ4[.1 I `:(
(or Removal) " -- tery , 9
A CERTIFICATE OF DEATH of I -_ _ ----- -_,
(Give f all name. a d)
having been presented to me containing the a ve stated particulars, . fter c eful examination,
the same appearing to be COMPLETE, CORK CT, AND SATISFACT RY AS REQUIRED BY
LAW,I have accepted the same for registration, have recorded it in my Local Record with
the above stated Registe ed Number,and on the basis he eof I HER B GRANT A PERMIT
to_._a_._g .__ .._., : ,
(Name f Un er (Ad
the__. to the body.
(U esker or person?}a ng charge of co se) (In f/o�vggr oth e dispose state how])
Dated +Z. 191.L( (Signed)__
Local Registrar
is Permit is sufficient for the Removal (and Interment or r ation of a body to any part of the
State (subject to local cemetery or other regulations), provided,that ere r oval is by common carrier,
the above Permit must be included in the Transit Permit.
12-80-15-25,000(21-13047) >
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