Surprenant, Alice 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
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
/,(!f � gistered No.
V 4 i../. } � /� (2)1J2—'L Town
Dist. No. Count Vil}age
or-City (If ity,give street address)
Name of deceased (2-a .-r::e. ...... ... ..�. _./1.-
// ) Ingle, married, widowed,
Sex. �sl a ,�oloa. )a
...or divorced (write th word).0 N.G Date of i.. 2 z- . ..19
i.4 Z.--
Age Li - Years .ice b the , Days B. thplace G � a z del e-
Cause of Death .d — (e
��-�-� 7.:.
Certificate was signed by ... ... ... .. .. ...
Address .. . . ,?Z.
...
Place of Burial (or Removal) - ( .
(If body is to be temporarily held,fill in sp
Cemetery ,Date of Burial ti/a .J 19..K.
(If body i to be temporarily held, fill in space later)
The Certificate of Death containing the abov stated particulars, having been presented to me, after careful exami-
nation, the same appearing tb, be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have acce ted the ame for registr ion, have recorded it in my Local ecord ' h the above stated egi tered
Numbed on basis eof H R Y GRANT A PERMIT
to ' . . ... .. .. . . .. .......�..".
'a ) Address) I
the.,,.. .. ...... to hold temporarily a the b y.
( e on rinx charge o pee) ante , em ve,or of erwise dis*� se of[state how])
Dated ...19..47'f (Signed) .... .... . .
Local Registrar
i� Permit is efficient for the Removal (and Interment or r ation) of a body to any part of the State (subject to local
fallses 'her regulations) unless removal is by common Barrie in which case a Transit Permit (VS No. 62) i quired.
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