Tenio, Regina Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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
DURABLE BLACK INK. Registered No. .! 4
DEATH, LEGIBLY WRITTEN IN
� T�u�.
Dist. No S 6°/ County.... �lftge
. or City (I lty,give street address)
Name of deceased �/� �- P'
W�Srrrgle, ..arried, weaved, i/
Sex Color or-sliverfed (write the word)..,�9 Date of Death.. ./ 19,Y'
Age '// Years f Mo hs // D ys Birthplace . ..R, ti�
Cause of Death /. . . •
Certificate was signed by 1!`" .... .Cr �""' _ -n....M.D.
Address
Place of Burial (or Removal) ; .
(If body Is to be tempo} ,1thel fi s e later) �}
Cemetery �rD'�! ate of Burial .! 19V
(If body is to be temporarily held, in space later)
The Certificate of Death containing the above stated particulars, having been pr ented o me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted t e. a e fo registr 'on, have recorded it in my Local Recor ith the above stated Registered
Number, a ^�' i reof BY GRANT A PERMIT G"
to /,( J
(Na ddress)
the �2 to hold temporarily and.. / the body.
(Un taker person�aving charge i.'corpse) //ate ove or other $e d' e o [s how])
Dated �G 19 Z— (Signed) C
Local Registrar "
This ermit ' sufficient for the Removal (and Interment or Cremation) of a body to any part of the State.. (subject to local
•metery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62)' is required.
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