Brown, Clara Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rAr 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 URABLE B CK INK. egistered
Towns j
Dist. No V.�... County .. . �....,,. Village.../... •
!:
,, (If city,glue street ad as)
ee •
Nam‘eesze
f deceased/. z • .
�' { Single, married, widowed, qSexolor. ... • or divorced (write e ord . .... . . .. . .... . Date a -1� 1 0
Aga Yea a gnths.. ... .., ` .Days in lace Ck?�a. .ai
Cause of Death � . ... ...... ... .... .
Certificate was signed by... M.D.
Address
Place of Burial or Remo 1). .... .... . .. ... -�
(If body is to b porarily h II i e r) !.e.e w I/
Cemete '�� ``"'"`� Date of Buria . ... . . 4.7 19..�.v
(If body is to be temporarily held, 911 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 for registration, have recorded it in my Local Record with the above a ted Registered
Num don sit; tte=T APERMIT /
to r( `rl
(Name) i_ (Address)
the to hold temporarily and .the body.
( ertaker or pens suing charge o orpse) remove,or other • dispose of[ to vvi)
Dated. ... vrA... 0 19.1r0f (Signed).. ...
ocal Registrar
T is Permit is sufficient for the Removal (and Interment or Cremation) of a o any part 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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