Seelye, Mary Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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
DEA710 LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No......Z..L.. .........
Dist. No. 411..County al &divapi. NziT .7.ge.,e9/6,,,,,a,V,./..4 g-..
. .,(4.i 2......./ (If city,give street address
et .,
Name of deceased 0.4ele-alifirea4.
SeglideC, oloriedin .e, married, widowed,
r divorced (write the word) healeliele.Date of Death,' a.:,..19.*:(41.
Age ir Years 7 on / ..1:"ysi..40.444.egi4thplace. eiglk41 .efira, 4Ceavat,
Cause of Death
• •.
Certificate was signed by .e."74W..• - " ..... M.D.
Address 7‘7/ ‘ 54z-ei,e.,. al44/Place of Burial (or Removal) Oficiely ajrainit"Mite
(If body is to be temp))grily held,fill in space la
Cemetery ;Or.GOetter,riegreeekt, • Date of Burial 4, • 19
(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 foregistration, have recorded it in my Local Record with e above stated Registered
Num and on . / z
. is . GRANT A PERMIT.2:00e ole.di #00.1
o, ....
to
.0
/ Amy. k me) , (Address)
the (21 - ' '4" to hold temporarily and the body.
(Talseee;rvasoiLhayIng charge ,o (Signed)f corpse) ter,remo • se se o of[state how])
Dated.... .... 4-4 19 l'Y 1.•19<gelt •v• -A-X.—.
L al it s ar ' -
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of e State (subject to 7 A
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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