Smith, Powell 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.
LL 7 Town
Dist. NcY �!.County .. Village.... - A --
or City (If city,give street add
Name of deceased.:.... ,l ._.1- --
?`/`_. Ingle, married, widowed, �
Sex.I�� .Color. . . rr divorced (write the word). /,ram Date of De 19.q
Age.Z5 Years./ Months.. Da s irthplace I--Cause of Death .L..4'
Certificate was si ned M.D.
Address
Place of Burial (or Removal). �,' ..a.... 40.410V
(If body is to latt9laporarily held,fill in space later)
Cemetery. Date of Bur' 19..96./
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated par culars, 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
Nu ber, and on the basis th ' -#-I HEREBY GRANT A PERMIT - '
to „ z €
the ) to hold temporarily and (Address) the body.
( ndertaker or person peon having charge of corpse) (Inter,re e, therwise dispose of[state how])
Dare . ..,-14 19 ../. (Signed)
K 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
etery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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