Brussie, Agnes Form VS.61. NEW PORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CERTICATE OF
DEATH, LEGIBLY WRITTEN IIN/DURABLE BLACK INK. Registered No. q
Icr9
Dist. No-laL..county...l—.Ltniz.l lags J,�2 ....crc;- >.
�j or City (If city,give street addres )
Name of deceased ..
aa�� � Single, married, widowed,
Sex�/.`.E� ee Color .. .. or divorced (write the word)..` .a t--. 4l.....Date of Death...'.0 e- // 19.° .d
Age to r Year NIontl , 2' D 's , Birthplace �M
Cause of Dea .th ...• .. ..,S"• ' !/G r
10)
Certificate was signed by -�-et-. ,, ..Gr a M.D.
Address G� /��
Place of Burial (sr Removal) .. L` G.eC�GrL.rL.. � .,•..� .
(If body is to be tern R*uily h , in ep e later) / ,(�
Cemetery.... •t..x .,... . 12 .., r.„4 .Date of Burial.... ...../,, ,' .............19(.11..
(If body is to be temporarily held, I 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 stated Registered
Number, an op the sis h �3 f I HEREBY GRANT A PERMIT ..40.�r
to - �.ext-Z !�G(Yl..-
/ ) (Address)
the •L/ to hold temporarily a co .. . .. .. the body.
(Undefier or yerson having charge of corpse) / " (Ihter, e er a dispose of[state how])
Dated ... 19.161. ., . (Signed)... .'OK
Local Regi ar
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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