Varney, William Form VS. 61. 8-16-35-50,000 (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
'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, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. '- O/ 'fihk% :f eg
� d No..
�— �
County Town
Village Pt � �% t••�yj %n
�/
Or City (If city, give street address)
Name of deceased.... .... ...._..........
Sex.j�f , Single, married, widowed, - /� // p
Lt Color or divorced (write the word) ... Date of Death.l��2 `'—- ..1...1.. ...19..cd a
Age Ye s M the 0 Days Bir ce.. � / 11 ..--
Cause of Death . .
•
Certificate was signed b . .... - ...y... -/ M.D.
Address
Place of Burial ,r Removal). ._. . - �
(If body is to be •• • ,. r) `
Cemetery ��% '--� Date of Burial �7. 19./4..
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated articulars, 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 registrati in, have recorded it in my Local Record with the above stated Registered.Number,
and on _ sis thereof, REB '}' R A P1 RMIT ,, ::::_,,z_dx2._
r ,yj /iv- 1--, - / , ,_/---,;
e) Address)
the temporarily to hold tem oraril :.. the body.
er or r e, or otherwis spose of [state how
(IJ er via� charge of )
�dn h how])
Dated ..., , . j•.f"f 19 5 4,11 (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), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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