Pike, May Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District ( own,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFiCtj E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.......__
Dist. Nof.6..l�.l.....Count .. .. ,
or City (If city,give street a less)
Name of deceased .1 11
\ h Single, married, widowed,
Se .. . ... . Color or divorced (writeo�the word) Date of Death 11...19. �
Age....7.. ............Y,e��rrs - Months cp ... Days Birth lace.... ,/ 1c%!
Cause of Death...(.�!J,....i l 1 �+ `, G%'C - .... i c-0. � Li
Certificate was signed b .. . .,.... ...��i Rn Ge M.D.
Address +x ,z- , ' 4--e---(-1,4 ")i.
Place of Burial (or Removal) ..e -.' :2.4. ,(If body is to bet orarily heist, n space late )
Cemetery . . -e- '- tl- Gr. Date of Burial 47 19.,W
(If body is to be temporarily held,fill 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 Record with the above stated ter
Number, and on . 4asis reof I HEREBY GRANT A PERMIT _ j, _____dee_24. teext.42 , eti
a e ,-(A dress)
the to hold temporal' and 4 th body.
(Wertajlw or person having charge,oyy orpse) erwise e of tate owl)*
Dated.
�r' ...1 ...19..Y (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a dy to any part of the State (subject to local
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