Kenney, Edward Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
e 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. 0 iatered No..
L /]t Town —
Dist. No rl b County -c4-1-[�� Vitt�aaggpr�e��
-
rri tt or e../rat .. . (If city.give street address)
Name of deceased 4 C a......... :. ...... ... .. . .P�
Sex?",
/// Single, married, widowed, /` Air
Sex ` , Color/1 or divorced (writ9 kite-word).r4-1.4cc ...Date of D93th 4,4 19.141
Age. 4.0' Years 1�- �,t..Months /1S s • , Birthplace /a,� w. n-ee. 7�. -
Cause of Death �a.tr.'z,A.71 . .
Certificate was signed by.. l CI.,T... .. .... ... . M.D.
Address
7..e�••�:>"
Place of Burial (or Removal) ���`
(If body la to be temporarily held.fir flitter) � -�
Cemetery ..c n`a"e. U. cfrefi ' C.4..sos.,..Date of Burial 19•5f.tO
(If body Is to be temporarily held. fill 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, and on the aka therp7fjl F ;FIERY GRANT A PERMIT c y- �
to - c...:r....i.. . . ( (f Gr. k,{� ////
'am tese)
the ` 'S. to hold tempos G((v the body.
(Undertaker or person baring charge of rpse) ( ve o o berw ere"[state bow])
Dated t...C.c.:....s,( 19 d (Signed)
/ Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a body to any part of the State (subject to local
cemetery or other regulations), unites removal is by common carrier, in whit can a Transit Permit (VS No. 62) is required.
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