Boviar, Jerry Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
vir 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 CERTIFI TE// OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Re istered No...../ "7
Tower
Dist. No.,,5h.Lt,/..County. Villege.
or City (I1 city,give street address)
Name deceased G'.'F4---'
ngle, married, widowed, /
Sex. ' _Colo ....�• or divorced (write the word .. .. . . Date of Death • 1 td
Age Years Months.. /7 Days " ' thplace, C�-.� — ...
Cause of Death �' ,
l
Certificate was signed b}i��.... .. M.D.
Address -
Place of Burial (or Removal) c=0.., ,
(If body Is to be mporarilp�e1 ,e d, pace lat
Cemetery 11�Z2. ��.,,�',4-0� .,,......Date of Burial /1 ,, 191��J.
(It body is to be temporarily held, fill 1n space later) (f
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 accep the same or„re ' ation, have recorded it in my Local d.with t above stated Registered
Number, on the EBY GRANT A PERMIT .
to. ... .. ,! 4011PS
i •
.ss)
the 4,2-rl to hold tempora •v�fs:�r� ��' _,,;-4,:':.5` the body.
(tines. 'ker or person h ng charge o1 orpse) (Inter >��'. . +Zrs di pose o state how])
Dated., . . .-%.,,..•; J 19..U,�.e 7 (Sign=s . . i': ��' ..,. fir ,
ilir Local Regis
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pa of the State (subject to local
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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