Willett, Mary Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 RABLE BLACK INK. Registered No.
( — Tbws-
Dist. Nc/.:. County. .. . Village.../ .... - -
(If city,give street ddress)
Name of eased ..... ... . . .
Singl married, widowed, q
Sex .,, olor •_ ,.or d. orced (writgthe word Date f eath.�./1........19.1
Age Ye onths.... .. . .. ays i pla /7•
Cause of Death
Certificate was signed by ... ... • M.D.
Address •
.. . .. .. ...
Place of Burial or R va1)
��,Qee • ,
(If body to be porarlly ld%� '"Sre later)
Cemetery .. (l� Date of Burial... .. .� — 19 t
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented me, after careful exami-
nation, the same appearin to be COMPLETE, CORRECT, AND SATISFACTORY S REQUIRED BY LAW,
I hay ccepted the same r registration, have recorded it in my Local Record with the above stated Registered
N .44.4.....17
. f « •. j.HEsg GRANT A PERM � 4...eg-v
(Name) (Address)
the ,c to hold tempor .1 an the body.
,t, d • ., orprson charge4f rpae) Inter,remove,or o se dispose how
Da -I ./.... 19. (Signed)
.. . .. ........ . ....... ... ....... ... .
Local Registrar
This P.. / is sufficient for the Removal (and Interment or Cremation) of Eo any part of the State ( ubject to local
cemetery or other regu.,zlions),unless removal is by common carrier,in which case ransit Permit (VS No. 6n) is required.
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