La Valley, Catherine Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 CER FACE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No./.�Y .... . -..
Town L.
�j
Dist. No.5.64.L..County......k. vt4-2 ' Village.ea.,,.._%G�A./1- F�� f'L•
i � Or Cl (If city, give street address) ,
Name f deceased 'a•...
... . .. . . . .. ....
Agi ngle, married, widowed, /
Se ,l/4 olor ��` `/r divorced (write t word Date of Death."' !..(. / 19 ''Ve
Age .O / Years T Months ys ..Orthp ce.. .. r
Cause of Death ,,.(tJJL.( � - *p'�7Z --,Cry, r
Certificate was signed by...,,". M.D.
Address
Place of Burial �,sr Remov 1� i ,ros�ca,... G.,. ,L�,�1L. y
(If body is to . e . ar e ,fill space later) L
Cemetery...e!. ... �t•d- Date of Burial.. /.,s 19.4(0
(If body is to be temporarily Id,fill in space later)
The Certificate of Dea 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 ac epted the same for registration, have recorded it in my Local ecord with the above statedta� Registered
Nou , and an b eof I HEREBY GRANT A PERMIT g--
��%. . . . .. .. .
,�
ame � ddress)
the to hold temporarily d 1=71. the body.
(u. taker or p rson having charge oj'corpse) (Inter r o 'se dispose of [state how])
Dated.„40. . i.. .. 19.... (Signed - ,, /"
ocal Zthe
r
This •l it is sufficient for the Removal (and Interment or Cremation) of a body to any 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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