O'Connor, Lena Form V .61. 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 IIJN/DURABLE BLACK INK. Registered No... !4
Dist. No�24.. Count �v G�' Town
/� pff y�), (If city, ve street address)
„.
Name of deceased.. —mow //,, �=G�zwx 7
Single,Unarried, widowed, 8
Sex -,r-L^-<t.Coloreter divorced (write the word) ��� Date Death. ' 19.. i
Age , Years. /..1. ....Months D s r Birthplace. ,U 2.t<,--
Cause of Death
,
Certificate was signed by / ..,... ... „ ,, ,., r s- M.D.
Address ,/.-- / ,�, i- 1/! ,t
Place of Burial (or Remo,vYal). /,.. .. '�c,�e.�i►� , 1 1- , Gv /r_e--n1��,�ti- �
(If body is to�e-etmporarily">}gld,fill in spacer) _�' r
Cemetery.P .9,- ��//4 4' Date cif Burial �& ' / 19 V
(If body is to be temporarily held,f111 in space later)
The Certificate of Death containing the above st led particulars, having been presented to me, after careful exami-
nation, the same appearing to he 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
Nurnbie , . • on dd! bas' ,thereof I HEREBY GRANT PERyl
7,2---4...„6„tiz , ,, ,
(Name) (Address)
the ., to hold temporaril and ';." the body.
(IIn• • ker or re ha ng chargelf pse) (Inter,remove;or oth se dispose of[state how])
Dated 7/ 19 • 'd (Signed).. . �I ` -��
I �" Deal Registrar
This Permit is sure-ient for the Removal (and Interment or Cremation)bf a body to any part of the State (subject to local
cemetery or other relit.. :ions),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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