Day, Mary rrrm VS.61. NEW YORK STATE .DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District Town,
Village, op City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERI F
DEATH, LEGIBLY WRITTEN IN DURA E BLACK INK. Re tered No..
eN
/ !�Dist. Na � ( County e
ic<4? )9 Or ity (If city,give street addres
Name of deceased
Single; , widowed,
Sex�444 Color arced-(-write the ord)..f'� Date of eath .. / 19.T':1..
Age Years.. .. a...Mont 2' Days firth ace `YL- .
Cause of Death....,....... . ... .... —/
Certificate was signed by.... M.D.
Address '-21, ,
Place of Burial (or Removal) ¢i�'h ..
(If body is to be temporaril ld,fill in ap la r>
Cemetery - .. Date of Burial 2 7/ 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 appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same or regis atio have recorded it in my Locall Record
�with the above stated Registereav d
p
Number, a on the ba BY GRANT A PERMIT d ��"`���K�Pi Q, - f- ,c.
to
(Address)
the to hold temporarily and. �,....the body.
(Unde akee ers9 i hy�ving charge_of corpse) me ove,or oth se di:,' - , , �`0 1)
Dated �i L. 19..`f (Signed) t .'
... ... . .. ...
Local Registrar
This Permit is.sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( ubject to local
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