Robertson, Sarah Form VS. 61. ) f 7
NEW YORK STATE DEPARTMENT OF HEALTH ,Ai ` ' (
OFFICIAL BURIAL (OR REMOVAL) PERMIT
`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, LE9B Y7l EN IN DURABLE BLACK INK.
Dist. No..-tV�,4s / gistered No.
Town
County _village
; .0.72' (If city, give street addre
Na e of deceased ✓ .a-�/. . �. .. .�,.... .,1-A' l� ........ ...
' gle, marri widowed ��, /J
Se olor.._ r divorced (writehe word) afra ff Date Death... .. ... ..._.... ....a2. 19.tt...V
Age f j Years , Al:QL
Months ... .j)a • Birthplace \,7 - '-i-c ./
Cause of Death
Certificate was signed by �� _)i. .... .... ... . ... M.D
AddressV fl 'r�� t_t
Place of Burial (or Removal) r27—Ze,riteti_c
c7 ___.
(If body is to be temporarily heolp in space later)
Cemetery .. ... . ,Ll�� ' � �......t Date of Burial. �... ., 19.. .
(If body is to be temporarily held. fill in space later)
The Certificate of Death containing the above stated particulars, having been pr sented me, after careful examina-
tion, the same appearing to be COMPLETE. CORRECT. AND SATISFACTORY AS REQUIRED BY LAW.
I havq'accepted the same for registratio , have recorded it in my Local Record with a above stated Registered Number,
and oh the basis there I H R BY A PERMIT
( ddreu
the �. _... .. .........._.... .� _ to hold tempora ' .. .... .. the b dy.
B (Inte, e e, or otherwise dispose o [state how])
(Under ker s n ha ' cgar a of c se
Dated...,- .1 19.t„,, (Signed) rye.
.. .i. Local Registrar
this Permit is sufficient for the Removal (and Interment or Crem ' ,a ody-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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