Wallin, Raymond Form vs. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
air 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..5 7...S 4 Registered No
own
County U Q.4 -.• T Village R.•.. ._..N.,./ A-, .dw/'d/.. : „
{J4:07-citY �q fI r(If city,
give street a
ddress)
Name of deceased V� G - �J.�J.C�J.I Single, married, wi wed,
Sex 14Alll...L Color 111.\ . or divorced (write t e word).Vil.,,AJ LLAMA_.. Date of Deathc. 19.1 .?
Age 3..9 Years a Months..........,a.. L n Days Birthplacel.kVr ...t . t..i4t.'.
Cause of Death Q��J1_L7. ....� 1..¢ %�Sc............_...
Certificate was signed by ( ., ' ......... .` .. ,. \ M.D
Address 54`a advutak.4 x."1. i.r, ....
Place of Burial (or Removal) % Ci `
(If body is to be temporarily held, fill in a later) ` ` -'
Cemetery r,1�1L.�,., V.,,,L.SLA.A ' Date of Burial `J lst 7 19.C..2
(If body is to be temporarily held. fill in space later) f�
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 SA'I'ISFACT<.)RY 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 the thereof I HTZEIW GRANT A PERMIT
to
(Name) A1164 (Address)
the V4 M to hold temporarily and the body.
(Un • ak r perso eying charge of corpse) (Inte remove, othan,.ieldi (state how))
. (Signed)
<` . !!
spose o
I>at tI ., ` l 9..r,�.� (Sgtl )
I oral Registrar .
This Permit is sufficient for the Removal (and Interment.or Cremation) of a body to any part of the State (sweet to local cemetery
oz.o other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is requi
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