Crosby, Daniel Form I'S.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
v' This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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 N DURABLE BLACK INK. Registered No.
// Town
Dist. No lst. .County . .. Viiiage
f�iy�, (If city, give street a ress)
Name of deceased g( 4C rn CITY
ff Single, married, widowed -- ee
Sex.. .... .. .Color.V� . r divorced (write the word) . .... . ate of ath........�4-.. ...' 19. ./
Age.I /...; e Years Months.... -- / .Da s Birthplace...
Cause of Death. .. �. q,.l. ,t�t..1 l'144-'fig-, ' yo.4.444,-
Certificate was signed . ... . .:.a .. . 4Rr4�1 M.D.
Address..1.9..I..... .... . ...., .... .....
•
Place of Bu 'a (or Remov:. -. ��ttcc,�-
(If body is to oornriiy he tto,;sapac ter) `" nn
Cemetery .; ... Date of urial�� .: .,...' 19.4)r.i
(If body Is to a temporarily held,till in space later)
The Certificate of Death containing the above stat particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, C RRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with a above stated Registered
Nuq}ker, thA bEsis er I H EBY GRANT A PERM�IjT 7
etzt ame ( e s)
the .. to hold temporaril L / the b y.
(a taper or poison havingcharge of corpse) U�I e o e,or otherwise nos o! state how])
Dated I`� p I . 19tt l (Signed) ,.. ./i2� L�
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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