Van Heusen, Preston Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
s2r 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 DU BLE BLACK INK. Registered No. J rrf
// Thwn
Dist. No 0../ County... . .... V-itiage..�.
Or Clty/ If city, give street a ess)
Name of% deceasedec /��neter-
�,//�
x%��""� `G/ Single, maimed, widowed,
Se Color or divorced (write the word Date of e h. iu 19 %Z
Age 7 Ye -s ..Months 7 ° Days Birthylace. ��000
Cause of Deat Q..��/
Certificate was signed by A.. ; .. M.D.
Address r'a�%
Place of Burial (or Removal) TT�
(If body is to be tempo arily held, it space later) 7
Cemetery r Date of Burial.. " 2"" 19.` L
(If body is to be temporarily he d, till 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 he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for egistration, have recorded it in my Local Record with the above stated Registered
Number, on th s" f I HEREBY GRANT A PERMIT
to .2-,./ Al—40-16..., /4;14 •
ddress)
the to hold temporarily an .... the body.
(Un take pars having ebargq of corpse) ,remove,o e ' e dish f state how])
Dated 19.k` (Signed)
Local Registrar
This Permi ' sufficient for the Removal (and Interment or Cremation) of a body to any part of th 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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