Hopkins, Bert Berm VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the t ocal Registrar (Deputy or aubregietrar) 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- r
q ,R, Tnvn r /
Dist. Nos�Of....County Y•r}}aGe... - ..cnc.c�
�� / �-C• (If city,give street address)
Name of deceased dC1�i�f �r....w/ �� y „e
pp��,,�� _ ngle, married, widowed,
Sex.../.f.LL L.Colol 6t divorced (write the word)cG2W- L4.C,44,Date of DJ th. .9 19..Yc,...
Age hi, Years ✓._a \Ignths Ta/ Days Birthplace 0•704,
Cause of Death.. .. tit..fi�. �. .n , �/
Certificate was signed by eg•._'cZ LtiR?.....,2fe • M.D
Address ,; ..:.• .
Place of Burial or Removal).. . � w
(It body Is to toyy��Dorerlp•he d��gg��to space late{) / - - /
Cemeterv..4l!_Lg�,rE2eQ v!C/ rT...LL�,:�� Date of Burial.�QQ,[so�.okiii,l..r.��...,19..`�l
(If body him be temporarily held, Oil 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 ecord with the above stated Registered
Numbs td on the basis t r I R GRANT A PERMIT
to .... • .. ..`. I• ', - ... r )l' .. •
( me (Address)
the to hold temporarily and ...`-� i . }� the bod
( key o crson Is tIv charge,/comae) (Iz,Yr, ve,or her % .%` to howl) y
Dated • oJ0 19 `f' (Signed) .. .. /./
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 'tate (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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