Cardle, Emma Form VS. 61.
NEW YORK STATE DEPARTMENT OF HEALTH _
OFFICIAL BURIAL (OR REMOVAL) PERMIT
!1irr 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, LEGIB Y N IN DURABLE BLACK INK.
Dist. No. N,;,1.. .... Registe No.
Town
County
(If 'ty, ive street address)
Name of deceased...._. ........_... . _...ee _....._.........._...._._..._.._ _._....
Y Single, ced(wr widowed, ) ��» �
Sex... . Color ......._ or divorced waste the word Date of Dea 19. ..
Age......._..... Years 6 '4 the a Sys Birthpla .... • d.,T.�..�e. .•.�.. ,
Cause of Death iie.t. . ... .. _.._...._ .._...._ ..
Certificate was signed by (2.n...... .... t .. .. - _ M.D
Address —e.L.. .4.4 .
ct . <2...Place of Burial (or I emoval /70 --
(If body is to be_temporar. held l in space later)
Cemetery 1��,rst-�._... ...,t Date of Burial ( 19.
36
(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 a cepted the same for registrat' n, have recorded it in my Local Record with the above stated Registered Number,
and` M the basis t f I�EBY T PE
=1.1;, 9.CC,e(
_fF m0 ( )
the - .. _... to hold tempor ' nd....,,.. _. ....„r.�t.. ...the body.
dertaker or son hake akarge of c - a� ( r e, or otherwise dispose of [state how))
Dated... . . 2 r ? l/ 19.......r (Signed).
. .... .....
Local Registrar
s Permit/i sufficient for the Removal (and Interment or Cremation b y to any part of the State (subject to local cemetery
or--other reguia ons), unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
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