Suckman, Sarah Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Its This Permit can be signed only by the Local Registrar (Deputy or subrelasfrer) a 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 DURABLE BLACK INK. Registered No—rel_____
T-own•
Dist. NostiO, Countyrdeens-httel Wage ,,1-42"fro Ye t I C•, 21.eter derde
(it city.give street ad ith)
Name of deceased.......22 .2cel.,,tecriksZetteen.City
v Sex,140.0.1...Color ,Ati Single, married, widowed, Itgeta
WAW or divorced (write the word). . Date of D thtigitifelt /5.0-- 19.4/.1
Age.. siZ Year 2 . pl9uths se..f Days eatuaLthplace .
Cause of Death.... ..0141.4teniatax.‘„ ..ce .i.. atietenps...f."60.,
Certificate was signed by 77earen- )4 • M D
Address
Place of Burial (or Removal) vaxteirt- Al
(I;body Is to tem ratify b d, MI pace later)
Canetery. Date of Burialniiiita /4, 19.i
(If body 4 to be temporarily held, ell In ace 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
Nutr, and on th basis thereof I HEREBY GRANT A PERMIT 44
to... ...0 a
(Name) ( rem)
the to hold temporarily a the body.
(Undertaker„or person having charge 9;corpse) inter. or rwise!bayse of(state bowl)
Dated...2n44:ent- zil: 19.W (Signed)
al Re stray
This Permit is sufficient for the Removal (and Interment or Cremation) a a body to any art 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. V
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