Bartholomew, Helen Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
LI)" This Permit can be signed only by theLocal 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 ORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN 1 U LE *LACK INK. Registered No.._....--_
Vt7; awn
Dist. N'o �O C oun cr....��, ilia e __
' / f city, give street address)
Nam of deceased. V ��-R�
�/ Ingle, married, widowed,
Sexl . ... . rr . . olor r divorced (write e word) Date o' eath .. .... ......1.t
1921,
Age (.9 .. ears Months (1 s ' Bi th lace Rom . f�•
p
Cause of Death ..... ... . .... . .
Certificate was signed y - ... . • M.D.
Address
• ..
Place of Bu al or R..moval) s.• C `.,(., '
(Ifbodym oritrily held,fill in sp later)
Cemetery is to to Date of Burial... A ' a • 30 1•!..-
..
(If body 1s to b temporarily held, fill in space latar)
The Certifi e of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearin. to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I ha - accepted the s e r registration, have recorded it in my Local R rd with the above tated Registered
Num.:. :nd ;n the is . eof I HEREBY GRANT A PERMIT
to nllipp , •
theVVI ► v to hold temporaril a /areas) s the body.
it.- • er o .•rson having chart o rpse) r, r •,o erwise dispose of[state how])
Dated V 19 (Signed) •
. Local Registrar
This Pe mit is sufficient for the Removal (and Interment er Cre q) of a body to any part of the States (subject to local
cemetery or other regulations), unless removal is by common carrier, in whit case a Transit Permit (VS No. 62) is required.
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