Sheldon, Ella Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
vg- 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. ,-F,Y
Dist. No.1. ./...County. .AVi/Z/z:A-.7-- ri:Ige
49,14, . (",&Zr?z„.. or City (If city, give street addres
Name of deceased
Sex.,;:fle.4). olor V4/ or divorced (write Single, married, widowed,the word)0-44-14C4A-tetelZ Date ol.,Heath.dra 7- 19 4(/.
Age PG Years t .Months thplaceifeet41
Cause of Death
Certificate was signed by.. ... .. .... .. . .. .. . . M.D.
Address ,03,--erx4,-- - *--,-4 -7-/*:)) • _..."-
Place of Burial,' loyal -----5.---;.--:r14-,-7.c..,,.. ‘-'1' 'd ..
"414 11/
(If body is to b• •. pora v el in a ace later)
Cemetery Date of urial 9.
(If body is to be tempo rily held, fill in apace later)
The Certificate o 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
Numb and o the is thereof I HEREBY GRANT A PERMI
to e -
(Name) 12 (Addr
the... .. . to hold temporarily a d the body.
T rtak r or yrafflitaving chargeAcorpse) (Inter e o , erwie of[state how])
Dated. 19, 7 (Signed)
Loca4teg1strar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to a y part of the State (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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