Robertson, Marion (2) Form VS.61. 10-21-37-25,000(17-3459)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. 71
Town
Dist. No.5.6.Q1. County ; c3.,C'.I'.an. She.r.i.dan...S.t...,Islans...Fa11•s,.�t.Y
or City (If city,give street address)
Name of deceased I.I.aX'ioX1...A.....Bolart.S.QSl.
Single, married, widowed,
SexFe&. ..Color i. i.Q..or divorced (write the word)..17..i.d.OV.e.d Date of Death...F.�:bi...•2.6•, 19.38•
Age....0 Years 1.1. Months la Days Birthplace 41.b•a.tiv.,.1.1..11. s.-1.Oy
Cause of DeathH.Y.P.s.r.?.gaMQ.117.a.- ,...Yr.A.-.1?;y:.Qioneplar.i.t.1..s-ui th...u.r.erti.a.-Ar:I as,.ar..t.erio.so.lero
l�:
Certificate was signed by Dr. Roger s. itchell v M.D.
Address Glans.... '��.��.,....I�T.....`i.
Place of Burial (or Removal) Q?)tee. tab z'y;, N*, Y..,
(If body is to be temporarily held, fill in space later)
Cemetery Pinevi pri Va l t Date of Burial 'arch...1., 19.38.
(If body Is to be temporarily held,till In space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, 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 HEREBY GRANT A PERMIT
to Seward....TA....F.Q.t.gr Glans...F.a11.s ...II.....Y..
(Name) (Address)
the usidarta.ktar� to hold tempor - .]�t.g.r the body.
(Undertaker or person aving charge of corpse) r re ve,o erwise dispose of [state how])
Dated .F.eh..... &., 19...3 . (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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