St John, Clifford Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 CERTIF7JTE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
Ttwft.--T- _____,e,42.0,ezo#00 .-h, ?
Dist. Noi di.l...County.. .
i (IP city, give street addre
Name of deceased / .. ��'' j C:�
pper�,, ly
gle, married, widowed, ys 7/
Sex.. olor. . .. ...or divorced (write the word <./�arG Date of .. 194?. Q
Age Years Mont D Birthplac ... ... .. . .. .. ........ �
Cause of Death
Certificate was signed by • M.D.
Address
Place of Burial (Removal .... .. ...�.. Fe
(If body is to be rily in pace later)
Cemetery... . /l Date of Burial ....,�� 19
(If body is to be temporarily ,fill in space later)
The Certificate of Dea containing the above stated particulars, having been pre nted to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same r registration, have recorded it in my Locaa}, cord with the above stated Registered
Noumber, a pn the 's th E�EBY GRANT A PERM�%Ml�� ,0��`�
?.
e) (Address)
the to hold temporaril d .,r. the body.
(Under er or person hang charge orpse) (I otherwis dis.)o of[state how])
Dated ziK,./d `" 197 (Signed).... .-.
��`�/// L 1 Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body t 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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