Everett, Cora Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
trar 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 DURABLE BLACK INK. Registered No uV _....
Y ��.7. Town
.,(.5.Dist, No. . .County- -ii-.Ol..r..Gi..t.fl- `�litillege... .X.i.ag.il .t►-.r.f
(If city, give street address)
Name of deceased YS#. Q. .,0..
ct .R.A.. Il 4.1.Q.4..
-G Single, married, widowed,
Sex.A Coloidl• or divorced (write the word).W.a.cAsaut., Date of Death.. . ..�1.....i. 19.2ila
Age...,2..h Ye rs i Months , Days Birthplace....ts�.:..c.a..a..y..(ht.. -ra.-r.YL...t-N.,
Cause of Deatll...,:°.. ..f.4 — .. .. a•.x..�.�.� � .,., ..g,. ...a.rt.� — k
Certificate was signed by..(. .o.k..c. .,eQ....�.,.... .c�F'►�0 QLvi...4r M.D
Address % 5...6..8 LLMw.s...o..LA. ... ..) $..9..�►►.`. ....�!L...iR(
Place of Burial (or Removal).. W.A. 1.11R,t.tP °rai.Q:.Q.A...,..... ....; �`
. s-
(If body is to be temporarily held,fill ijpace later) r�,,Q
Cemetery.Uk).:.t. '..?d..Rx.4...t --4..t'..�C.. Q.L..�.a.4..,R... '.2..r Date of Burial..`( 1 l►?.l..:i. 19.`!`i1..
(If body is to be temporarily held, till in space later) '—...
The Certificate of Death containing the above stated partic ars, having been presented4o 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 stated Registered.
Number, apd on Oe basis thereot I HEREBY GRANT A PERMIT ,,
to e.4,h:e... .../.1 s.t).. u..:,:t., .../..g 6..7..r . ..1. 3.. 4,11..e.t
p , (Name) n / (Address 4
the Lia.at,Q„ �I..n.+w.+.aa.n. .L to hold temporarily and... x.a.u.�....(Addres.a. the body.
(Undertaker or person having charge of corpse) (Inter,mmovp,4r other ise dis*pose of [state how])
Dated... ,a...e.. 6,-....A..; .� 19.: . (Signed) "7l.l:t,.o.,,, , _. _..�..14.griP.)`
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to 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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