Viele, Wilber Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
' ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion Distr (Town? tla e,or City)in which the death occurred after the FILING and acceptance of a COR-
RECT AN C CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No. Registered No..
County ..... Date of Death ` _ / � r..
Town
.
Town V Q !. Se w4.Age._ff1_/ Yrs. Color_ _
lage,or _ -
(Or Mos.)
(Cross out names not applicable
Cause of Death. - - " '
Place of Bixrl Ceme- _ .._ e o Burial /(f tqi
f
(or Removal)--? eery
A CERT ICFgTE OF DEATH of e.t.d.,'- -, -
(Give full name of deceased)
having been presented to me containing the above stated particulars,and,after careful examination,
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
stated Register Number,and on th 's thereof I HEREBY GRANT A PERMIT7yee
the"Vie Pzlpy fG_.. �__.� ^ ..
(Name of ndei' ker (Ad
t ._." 'f'i .k....r tO : the body.
(Und aker or person having'charge of corpse) (Inter,r e,or of e of stat ow])
Dated .� e /4 191_ (Signed) h 00� ��
cal Registrar
TIPermit is sufficient for the Removal (and Interment or Creme ion)of a bodyto any part of the
State (sub ect to,local cemetery or other regulations), provided that where removal Is by common carrier,
the above Permit must be included in the Transit Permit.
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