Murray, Gerogianna , Form VS. 61. 8-16.35-50,000 (17.1423)
% NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
SW'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 CERTI•FICATE OF
DEATH, .P LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No,,, ...f�. / Registered No
Town
County Village. .. city,. ..
Or Cit (If city, gives eet address)
/
Name o decease �... nC`' v
d - •• •• •••• •••
�f _ Ingle, married, Sowed, Date of De X19.,NT .
Se ... olol .... . . r divorced (write the word). . . .• //
Ag e.. 7 Yea Months./7 Days Birthplac 4
Cause of Death
Certificate was sign b
G e%f•01-fr� M.D.
Address. ..
Place of Burial (or Removal) i �
(If body is to be oraril el in space lat Date of Burilg �
�3
Cemetery....(�!'!..' ....... ..
(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-en the,kAsist REBY GRANT A PERMIT
!l y� .....
t .~ (Address)
e) i�
( •j ,, � to hold temporarily and the body.
the•••YL��j' k ter mov or otherwise dispose of [state how])
'7(�'7ndertaker or person having charge of corpse)
Dated 19 (Signed) ...
Local Registrar
This Permit 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), removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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