Wilkinson, Nellie Form VS 61. 1123.35-25,000 (17-5154)
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. ee�� c� Registered No
A Town ��' .
County Village
-or City (If city,give street address)
Name of deceased - .
Single,married,widowed, '' /
Sex ,Color 7�. .or divorced (write the word) Date of Death �7 /7 l t�
Age `f Year Co Months 2/ Days Birthplace /`
Cause of Death o
Certificate was signed by... M.D.
Address b
Place of Burial r Remo 1) ---(--A- /--A- v ---(—e----(--` —Y
(If body is to be tern arily held,fi n sp�
Cemetery ,,.... .. l �E'�! Date of Burial U 19`*
(If body is to be temporarily held,fill in space Eater)
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 on t basis er A f yER Y GRANT A PERMIT I //
ti
(Name) (Address)
the to hold temporarily the body.
(U ertaker r person havi of chaise , Inter,remove,o tl is i ose of[sta ).
Dated / 19. ' (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part cf 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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