Sanders, Clara Form r s.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 subregietrar) 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 INIC Registered No._-.—___—_ _
Town
J
Dist. No i Cotmty.. a/?/k-e+-4- Village:-ye.e.r vr% :i 1..
(If city,two tenet address)
Name of deceased..,... .�".7..,... ... . .rf!.r,
, married, widowed,
Sex.... _Color... . ....hh (writ the word), ....Date of each ... .. .. ,.y.�0 19 54 O
Age ie...,� Yea .2 Mo�ays BirthplaceaiL.:......... .�?..y
Cause of Death,.
Certificate was si ed/by... ... ,u• 21• ,�.-41,N M.D.
Address..
Place of Burial (er-&etaoval) .j`RrG& r,Z�
(It body I.to be�p porarlly held ep space later) O
Cemetery....L.4e !t Lam... �L.efifer Date of Buria1.71 (f,....le 19Y V
Ilr body Is to be temporarily held.all In space Inter)
The Certificate of Death containing the above stated particulars, having been presented to me, atter 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 Record with the above stated Registered
N r,a d the sirs f I HEREBY GRANT A PERMIT / iy
to... .. ��qqt�
f ( me) (adQZeaa) the body.
the..... .... . ... . .. . -•— to hold temporarily and.. .
rndertak r rgcvYtlytiae) //'' � (Inter, ..harry.sispose.ol-4atate'hai)
Dated a7�I9,j'Q.. (Signed) lr `-t-di '41.1."i4ti--
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (subject to local
cemetery or other regulations),unless snow(4 by common canto, in which case a Transit Permit (VS No. 82) is required.
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