Rauibam, Alice Form Vs. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rn 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 CERTI•FICATE OF
DEATH, LEGIBLY �Rj EN IN DURABLE BLACK INK.
Dist. Not.. J 6 Register d No.
Town
County.. ... ... ... Village
4';: n Or City (If ci[y, give street address)
Name of deceased a��,y��� _' ffJJ�^F(l[f/ ��w �o
� ` �01(' iv, married, widowed, )!'y Y '
S olor.... ... �(/� c Ivorced (write the word .. . . .... )ate of Intl // 19��
s.. ../. Days Birth >la' .
Agee Ye \ .` 1 . Geffi
Cause of Death.
Certificate was sign 2 y .LL.I2-- ` . - M.D
Addres•
Place of Burial (or Removal) .(e l �
(If body is to be tern arily held• fill ' space later)
Cemetery - Date of Buria /it 19. : "'
(If body is to be temporarily held. fill in spa ater)
The Certificate of Death containing the above stated particulars, having been presented to me, afte careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SA'I'ISFACTORY 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 the basis thereof I HE' a:Y_GRANT,A PERMIT
( ame) ess)
,�the to hold temporaril • nd the body.
(U rmakkee or person having charge of corpse) In otherwise dispose of [state howl)
Date. 19 , (Signed)....
Local Registrar
This Permit 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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