Pepin, Sarah 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 CERTIFICATE OF
DEATH, LEG - tiN IN DURABLE BLACK INK.
Dist. No...t/% c •' tered No.
Town
..County..1!1 ti=iliag• .
(I give street address)
Name df deceased...._...... .. . ... ... ... .. .... .. .
Single, married, widowed, '' ° -"'
Sex Co1or./44J or divorced (wr' e e wor )....._9.;�%IC. .t-�.,(.,�'. ate e f Death. �� l ....19.2..7
Days Bir lace.' A
Age �� Years � lanths �. Y p �. .. .. .... ..,f...:...,}r
Cause of Death (,O�i l . . ._. e— Z.4./2.-..
Certificate was signed by 4._ _- p %
Address
Place o£ Burial (o emoval) / �fi 1,4.7 .� _ L ..
(If body is to be tempo ri held, fill i pace later)
Cemetery....._................ . .. . .... .. .. .. .. .... Date of Burial 19
(If body is to be tem rily held, fill in space later)
The Certificate f Death containing the above stated part' ulars, 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 registration, have recorded it in my Local Record with the above stated Registered Number,
and onebasis theret I HBY JrT P 'MIT/ /Jf�
r/ 1 / (Name)
the to hold temporarilyand the body.
( or p having charge of co ) (I rem r o •se dispose of [state how])
Dated .:e.--- „J+t 19...3 (Signed) yy((��
' Local Registrar ilf
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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