La Rose, Baby boy Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 Nro.
�,,�� �y�
Dist. No..3f(o ill ...County Town
AFillege.. ,., , ; - :-[�.X�- �f. 7
y� Ar-C...6e0-•e-12--,-....,
ity (If city, give street address)
Name of deceased G �... '.'.,, ,..
hl..�am�,,,,,, . 'x Single, maW ed, widow l.',
Sex....172.(......Co1or. or divorced (write the word .. . . .,.. Date of Dea �... 04, 19 �1
Age — Years — Months Days Birthplace.. •3.
Cause of Death
Certificate was signed by L�.......3( • M.D.
Address ,. ,
Place of Burial (or Removal) CI.... .. .
(If body is to be to rarity hold,fill in space er)
Cemetery . - . . . . Date of urial......` 9 19.51
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above s ated 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
Numbs and on the bakis th fof I HEREBY GRANT A PERMIT
the ( dress)to hold temporarily and the body.
cuac__Ieytfit4r Ar person h ving charge o orpse) ter, e,or other se dizA of a ;/.ow])
Dated / -
..a� �........19..�� (Signed) !,N .. � ..‘
Local Registrar
This Permit is sufficient for the Removal (and Interment or C .. .. ... .___ _ _ _
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