Harris, Emmet Form V.S. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re 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 CERTIFIC E OF
DEATH, LEGIBLY WRITTEN IN DURABLE B CK INK. .. .. . Registered No.
,(- /� Town _ T
Dist. No...6711.. ounty (l..(/... Village
orb (If city, give street address)
Name of deceased . Q r 4
Single, married, widowed, 1
Sex...7 t .. ..Color / or divorced (write the word) 710(" ( Date of eath.. .c!^ ./
Age (PT Yeaj j.. .W yl\Ionths D ys Birthplace... . .. .. .d ... • .•• ••
Cause of Death C,.�. ...{
Certificate was signed by ,. M.D.
Address
Place of Burial (or Removal) 1— _?e �. .
(If body is to be porarlly eld,fill in space later)
Cemetery .. Date of Burial 19 ./.
(If body is to be temporarily he , nil in space later)
The Certificate of Dea containing the above stated particulars, having been pres ted to m , 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
Number, nd on the basis t r BY GRANT A PERMITto 26
am , ddresa)
the to hold temporarily and the body.
( nder er or pe on huviag charge of corpse) / 1 (Inter, remove,or othwise dl oose of [s to how])
Dated f 19. l �l.9/ (Signed) ./
Local Registrar
This rmit is au cient for the Removal (and Interment or Cremation) of a body to any 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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