Boliles, Fred Form VS.61. NEW YORK STATE •DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
112r 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.�iP�l�Coun Town
Dist. No .... County Village....
e or City (I!city, e street address)
Name of deceased. j ei0c-eafet—
We, married widowed
Se( Color... jar divorced (write the wordy lif ate of Dea .2.. q4....19r� .
Age 2,......Years. "f Months.... .... Days Birthplace
Cause of Death
Certificate
was-°sl d y.. ). ,‘(„ejet, M.D.
Address..
Place of Burial (or Removal) .. ..< � �1
(If body is to be orarily held 11 in space later) '
Cemetery . . . . .. Date of Burial. . .. ...2. .19�.].�f
(If body is to be temporarily held,fl space later)
The Certificate of Death c taining the above stated particulars, having been presente 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, andlon the basis th f--1� H BY GRANT A PER `
t0� (N ) `/ A �` (Address)
the . . to hold temporari .nd the body.
( n rtaker or person having charge of corpse) _ illr. .• • • .therwise dispose of[state how])
Dated . .Z 7.. 1R,FX (Signed).. l. - ./
Local Registrar
This jeagmit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
ce...etero Unnthor resmlatinnal_unless remnnel Is by common earner.in which case a Transit Permit (VS No. 62) is reauired.
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