Couter, Anthony Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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....1.7 r
//���
Dist. No.S6 01...County...1�/, . .,. Town Village. � Q� /�/f
zrc24.4 or City (If city,give street address)
Name of deceased.. ... . . . . .. . .. ....
/, "atingle, arried, widowed, ]7 ' /,�-
Sex . . ..Color. r div rced (write the word)./ite..4�r�`Z [�C„ Date of Death.. .. ,l e 19. Q.
Age 7 ? Years 20 Day BirthplaceCause of Death22,4040.diths..
K.
Certificate was signed by A- ..fG�rYf� M.D.
Address . .. z ��2� .. ..: . ..! �...
Place of Burial (ord,emoval) ..r� ?.�...., .. .. . N ��✓.
.9.,
(If body is to be t•.... :r hel 1�� spa t r /
Cemetery , . .. . .. .G b • Date of Burial. .. ,1.. 19.1 .el
(If body is to be temporarily held, fl in space later)
The Certificate of Death containing the above stated particulars, having been presente 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 Loca Record with the above stated Registered
Number nd on e ajjdf thereof I HEREBY GRANT A PERMI /r ,,e
/�
e) (Address)
the...... . . ... to hold temporaril d �� the body.
qadertaker or peon having charge of corpse) (In r t 'Ise dis')ose of [state how])
Dated... ,/6j, 19.fi'•4 (Signed) ...62/
Lo 1 Re trar
This Per s sufficient for the Removal (and Interment or Cremation) of a body to any p rt 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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