Welch, Baby boy orm VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ItAr This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) 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.Iy OF
DEATH, LEGIBLY WRITTEN IN DURR LE BLACK INK. Registered No. QI 0/
! 6/..,eae
Tow..
.
Dist. No (DI County r� c i.
/ (If city,give street a dress)
Name of de eased.... ...... ✓. •�...
Singl marrie. widowed, �`
Sex/ Colo or divorced (write the word Date of ��h. 19
A e Year Month / D Birthplace.
g
Cause of Death...: ... . ....... . •... . ..
Certificate was signed by . M.D.
Address , . ... . . .. . ,. `
.r /t ..
Place of Burial (or oval) •
(If body is to be temp•f •he nap a later)
Cemetery '!• ••.• Date of Burial Y '> 19..KZ-
(If body is to be temporarily held, 1 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 acce•ted the same for registration, have recorded it in my Lo Record with the above stated Registered
Number ..1" on the ��t�ye} o BY GRANT A PERMIT !
to
Address)
the to hold temporarily an the body.
(U aria or persjtn having charge of corpse) n e,or of 'is pose of to how])
Dated .. 7 19.. (Signed)
Local Registrar
Th Permit's sufficient for the Removal (and Interment or Cremation) of a body to any part of the St a (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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