Boqinet, Virginia Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
K This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Ton
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE Ol
DEATH, LEGIBLY WRITTEN INLACK INK. // erect Y ._.........._...._._._......
Town U f
Dist. NoS 0/...Coun/l`/ �.4CK I N Village '6 ei
U-A ��yJns r Ci (It city.give street address)
Name of deceased ��"�
/Single, married, widowed, p ,
Sex . a.. to divorced (write the word) hi7k .Date of th.. .��
A D a .... itfo s a?.. .„Days Birthplace. ... ... .. ... . .. .e
C use of Death .. e2-4-C:iacti .IZ/... . ev.wSi..4r.. 4.Ra
Certificate was signed by r. ... .... .. Mt
Address i.... "�...
Place of Burial (or Removal)....11J/.it4T
(If body 1s to be to arlly h d a a later)
Cemetery.oI.to a to Date of rial •
C 4n /3 19..ljF.
body 1s to be temporarily held. 011 n space late[)
The Certificate of Death containing the above stated particulars, having been presented to e, after careful exami
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW
I have accepted the same for re 'Oration, have recorded it in my Local Record with above stated Registeret
Noum i and on the aiti the 4 I.HE =BY GRANT A PERMIT a- /J/� y�
eme�/)hbb�`_OO--r�� (Address)
the FL
the .. ... .. .. �'�,-krG� 1 to hold temporarily and the body
Wed a or person g� a of corpse) ( , renee, t r ee d o of Ceuta how))
Dated....,. ! 9..Y./. (Signed) �. . w
/ Local Registrar
This Permit is (ttfficient for the R..moval (and Interment or Crematio of a bad o any part of the State (subject to Ina
cemetery or other regulations), unless removal is by common carrier, in wh case a aneit Permit (VS No. 62) is required.
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