La Point, Kenneth Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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.
Dist. N .4„ �Count TownVillag
Or _.1.If,city,give street a ress)
Name of deceased 2 .�„ �, . � ,
ingle, married, widowed,
Ser Colat r divorced (write the word �ig/ Date of Dea ... ...../ ....19..,.
Age. Yea _c .v Monthsa � Da s irthpl
Cause of DeathG.�r�. �yn . ,fi -�c��
Certificate was signe f ^ 4, � M.D.
1
Address.
Place of Burial (or Removal) .. .-- •••• sc
(If body is to be temporarily ,fill in apace later) .r
Cemetery.... .--- Date of Burial.. ,4-i-�-� ',?„ 19W..
(If body is to be temporarily held, n space later)
The Certificate of Death taining 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 stated Registered
Num , ant.on the thereof I HEREBY GRANT A PE.F .:
t �
(Name) (Address)
t , ✓,A • to hold temporari and . the body.
gipdertaker or erson having charge of corpse) r v otherwise dispose of[state how])
Dated ....te.-4. . . ./�' 19 ;5 (Signed).. i . .... . . ..
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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