Brodie, Flora Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
g2r 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. R tared No.—
Town
Dist. Net&J.7.Coun
Nam of deceased j()1AC6 o • c- (If city,give street add
*t
Single, married, widowed,
Sex73 ColoriliTz...or divorced (write the worcD4ati-":74egiCgate of D
.... . ........ ..............
Age vei Years i onths.. a s Birthplace
Cause of Death
Certificate was signed by M.D.
dre s
Place of Th.dial (rdetwval)
(If bo tem o y held,11 ater
Ce e Date f Burial. .......C. 19
(If body s to be temporarily held,fill in space later)
The Certificate of Death containing the above stated p iculars, having been presented me, after careful exami-
nation the same appearing to be COMPLETE, CO ECT, AND SATISFACTORY AS REQUIRED BY LAW,
I h , - accepted .e same f., re tion, have recorded it in my L rd with th above stated Registered
Nu.. , 4. /the has i 1.
'0' IliF HE BY GRANT A PERIM eerill Oty
to. .
40' At'a d re )
iftir to hold temporar. A i the body.
ma: r . . on sett c7se)
Dated (Signed)EiQ (In ve,or the se a of[state how])
19.. i se
e./P Local Registrar
This Permit * sufficient for the Removal (and Interment o .• • •) of a body to any part of the State (subject to local
............... -.. ..1.1... .....1.44...A wartime&ram,. ./le It.,rnremsen nervier_ • ethirk ream a Transit Permit (VS No. 62i is reauired.
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