Scoville, Nettie Form VS. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
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 CERTI•FICATE OF
DEATH, LEGIBLYWRITTEN IN DURABLE BLACK INK.
Dist. No...f.{{. 3 7 Registered No.
Tow
County........teL ........... �i�lag
—� or City (If city, give street address)
Name of deceased ) . ... ..
Single, inCried, widowed, a-
See' Color 40' or divorced (write the word).,�:f!L. Date of Death 19......3 �_
Age 6...f Years / Months..... ... Days I3irthl ce ..4e-us,emeN.--)e.
Cause of each .. .. 1 1 .... ... .c.. lop
Certificate was signed by 46.f M.D
Address y' - ' " ...X
Place of Burial (or Removal) �-�y.�
(If body is to be tempor eldt-fill in spa 1 er) (/e'C. �/
Cemetery ►..... .. .. f Date of Burial e � 19..3..r
(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 accepted the same for regis ation, have recorded it in my Local Record with the above stated Registered Number,
and o the basis thereo A PERMIT -91 .' D/
N e) (Address)
the...,./.. "<• to hold tempo arily an ........... — the body.
(Un eorr rson ay. arge of c s Int move, or o to dispose of (state howl)
Dated CA.-:' 19. 4 (Signed)... ..
Local Registrar
This Permit is sufficient for the Removal (and Interment,or Crem t f a body to any part of the State (subject to local cemetery
other regulations), unless removal is by common carrier, in which c e a Transit Permit (VS No. 62) is required.
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