Fisher, Minnie Form VS. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
INF"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, LEGIBLYY WRITTEN IN DURABLE BLACK INK.
Dist. Nov V " Registered No.
Town
Count - Village...
or Cit (If city. give street address)
Name - deceased
•
''oo �ngle, marrie , widowed,
S 1, C;olot�,tlrOX-.- .. r divorced (write the ti�•o ,,,t ILA 42, Date I D 8 1 X7
Age....t'�.O Yea Months-.----, Da ,s. Birthpl 1' """"'FY
Cause of Death
Certificate was signe ' . 4_ .. .. M.D
Address
Place of Burial (or Removal) , r4d,i,r rJSP s��
(If body is to be temporarily held. fill in space later) �
Cemetery Date of Bur' '.... &... 6 19. �
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented o 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 the basis thereof I - r--4'‘'cl;X. igMA solireeerei yele,
H Y GR A PERMIT
j90.4efetegiA.41/ 71# rame) ).
th . .. to hold tempura ' • and _.. the body.
ndera r or person hiving c arge of orpse) a re r 'se dispose of [state local)
Da . ... .. ,?� -*e I VA (Signed).. � �G�..-$----.::!=-e-'-`-----
Local Registrar
This P it 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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