Rising, Baby girl Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t' 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. 180 __
Town
Dist. No 5601 County Warren Village....f Lane .7AU. 111.,Hospital
Bab Girl Risingor City (If city.give street address)
Y Name of deceased ,
Single, married, widowed,
Sex.YellUalrolor W or divorced (write the word) Date of Death...t.W10.....1.4 19.3R.
Age Years Months Days Birthplace le 8...Falla,... eE..Y.prk.
Cause of Death A$P.14Y.Zi. -.'.eta.1...diyatr.00ler: '.raula erne..o.seiplation..of....sku l
Certificate was signed by Harold A. Ptla.a ,... .... M.D.
Address 306 Glen Street
Place of Burial (or Removal) t ,` : .. lens. .F.ala. i.,...I1T.ew...York.
(If body is to be temporarily held,fill In space later)
Cemetery 16 1ilt... i821.S...FALLS Date of Burial Amp 22, 19....59
(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 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 S• T. Potter eel iiarr. ...S:tres ...GlSnz...Fall.a N'
(Name) (Address) r
the Undertaker to hold tempora nd In gr the body.
(Undertaker or person having charge of corpse) ' r,rem otherwi dispose of[state how])
Dated June...22.7 19.....3.9 (Signed)
Regis
This Permit is sufficient for the Removal (and Interment or Cremation) o a y o part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a T Permit (VS No. 62) is required.
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