Hammond, Bryon Form VS. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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 WN IN DURABLE BLACK INK.
Dist. No.o-60 Registered o
Town --y
County..�:.. - OVillage
Or City (If city, give street address)
Name of deceased.... ._ ...�,,...‘.r. ... , . .. lee,
g e, married, widowed, -__ y
SeW,.4.,4....Colo .. .... ..., divorced (write the word .. Date ' Deat at; e.o..'�'� 19�{
Age....62, Years. Months 7 Days t Birthplacf...r
Cause of Death.. .. .. .. G
Certificate was signed y. .. — f`. A7 �•R- � M.D
Address . ... .. .. ... . . ... . ��
Place of Burial (or Removal) r-,� --...
(If body is to be rarily held, fill in space ter)
Cemetery ;::: . Date of Burial. 19.a p
(If body is to be temporari y held.'fit 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;oh the bpi) t eof I-HEREBY GRANT A PERMIT
�: .... :. ''LC.. -2---mot ,e. . :7.,�---
( .. . Name) 'Address)
th ,E l .. to hold tern iorari y.and.... .. the body.
(Und er oype avt charge of cvati t v or otherwise dispose of [state how])
D ted2;;:ai.::, L.i2 19s., / (Signed).. . . - .
t, Local Registrar
is Pe if i s ff cient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local cemetery
od'other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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