Kenison, Louis 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. Re ered No.
Town
20
Dist. NoJc,,1rj.County .. ... -` Vi1Tagt... .... .
t 9r-Cit (If city,give street addre
Name of deceasedi ... ..
��f Single, married, widowed, �,7
Se ...��.••-.Colore,,�li/....�.or divorced (write the wordy ' L ... ate o at r 19 .. ..
Age .f2/..Years spt Months / I Days f Brthplace... .. . i
Cause of Death '
Certificate was signed bye ' - !,j-j.Y.. .. . J M.D.
Address
Place of Buri. ; (.r Removal) ` i��.
(If body is to be t: ,. art el 1 a later)
Cemetery.... >, Qa- :a.4 .r Date of Burial <�'� �A"Z 19�e��Q
(If body is to .e temporarily held, 11 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 ac, ;.ted the same for registration, have recorded it in my Local Record with the above stated Registered
ielum•er. d o:el:7Z is reo'I EREBY GRANT A PERM �: f
to 9 <7.7(.." r `z—f-t ex. „ mac�T'C2 �`%
e)
,, to hold temporarily d _ -a- c-i, �ris,r -- the body.
r ertak or person a g barge of corpse) ,(Inter or otherwis�-flispoae of [state Low])
Dated.. ,l.:��a . .19...eLt) (Signed) t..'
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crem on of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier,jtt'which case a Transit Permit (VS No. 62) is required.
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