St Pierre, Ruth Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or ity) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, 1BLY WRITTEN IN DURABLE BLACK INK. Registered No.
Dist. No.Jr4/0/ County 7t.,sG� V 7 e .
. .. . .. . . ... . . ...
or City (If city, give street address)
Name of deceased... . .... . .. ....a,,,,,... " y
Single, married, widowed,
Sex., 4•Nt.taColor.. ..
� .or divorced (write the word)..22 .4v!flA- .. Date of�ea h... . .... .. t 7 19.�7.�.1
Age 7..sz Years r Months. ..c�.., Da s Birthplace 1
Cause"of Death` ""
Certificate was signed by . .D.
Address ! •,,�.,.!r/,... .24 A
Place of Burial (or Removal)...,,,4..O nZ. E 7, .
(If body Is to be vEpporar ly eld, ii in space later)
Cemetery... Date of Burial . . .... ....3 0 19.9/
(If body is to be temporarily eld,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
Numb r, and o the ba ' thereof I HEREBY GRANT A PERMIT aD,, },
,,
ame) • (Address)
the...y . . . to hold temporarily and the body.
ndertaker or perast having charge of corpse) movett other e dispose of to howl)
Dated.... . . 2 19.1/.. (Signed)
Local Registrar
Th s Permit is sufficient for the Removal (and Interment or Creme ion) f a bo to any part of the State
_r__ r___ __ (subject to local
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