Nichols, Mary t., 1 t..
Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Vir 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.
Dist. No..�..7 Y..County Q � g CN"^ Village./.q,../.,....1 ti -. A
V ( If city,giv s eet address)
Name of deceased �V1.sCK.A. U`I,,.
Single, married, Aolowed, .,q
Sex..'Fis9,4 Color....IA) ' or divorced (write the word).W Date ofa .peach I0.,2..e.. I 19.If 1..
Age Q Years I Months it Days Birthplace.MI �...ts'
Cause of Death.. .. ... . . ..w... ...7 . . . ., .. ..,..0A�S�.L i \-
Certificate was sign by .,P....-6.. -4-Q..C, ... M.D.
Addressn. 11 qPlace of Burial (or Removal) ,
(If body is to be temporarily held,fill in space later) ` "�
Cemetery r. .L....0.n.,Airr-' Date of Burial 1O.< .r 3 191i.t..
(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 Registered
Number nd on a ba 's th of 4 H REBY GRANT A PERMIT G:t
the � (Name) (Address)
. to hold temporarily and the body.V
(Und taker or person having charge.�9gff corpse) 1 (Inter,re ve,or o�,ierwi nose of[state how])
Dated UL4.. 2— 19..tip`..{ (Signed) .1�.9�.r1A ...?'r.......7...tA.. . '{'�`Q'''� �....
Local Registrar�,~�
This Permit is sufficient 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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