Lennox, Mary 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. Registered No._? 9—
Town
Dist. No..3.ai.t.County G/"'t-�- Village
or City of ci r, give street address)
Name of deceased `u;�
Sing e, married, widowed, -
.
Sex. for `' , or divorced (write the word) �" t� Date of Dea0, . .�_adcP�f�• a's 19 IL O
Age ..Years Z D onths Days Birthplace [f4----e1
Cause of Death
Certificate was signed by .d,r4V a e--C - M.D.
Address c. 4— X? ey .
Place of Burial (or Removal) GUAIrja y I,4ne Cemetery
(If body Is to be term.�porari)y bell, fill In space later)
Cemetery QA0.113..QY Lail,e...G.eG44t@rY Date of Burial September 27, 19.4.0..
(If body Is to be temporarily field.d❑ 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 he 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 basis thereof I HEREBY GRANT A PERMIT
to Potter Funeral Home 84 waFz'e.t>,,..S .e.,...5r.1,9Xl. ...Filll.p.a..111r
(Name) 3065 (Address)
the CharLes...K.e...D.enny to hold temporarily and /star and remove the body.
(Tiedg a tef or hereon having charge of corpse) ,q. (Inter, remove,or otherwise dispose of(state bow])
Dated D pL b 1*.Q,.. (Signed) c✓-�.o. A. eL¢..,�p] '�'
' U .0Y'er.�i Loct ritegistrar
This Permit is aufc-lent for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regt dons),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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