Sansousi, Frank Form Vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itr 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 CERTI, IATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.tea((
Town
Dist. No..5.ieV...County.... .- ., 1141 ge '1ef i p"-4,
City (If City,give street address)
Name of deceased -44-��
,m i Single, married, widowed,
Sex.. ..A
... Color .* • or divorced (write the word).. . .... Date of De t 19 .
Age > Y r- a Months �? 4;2— Days Birthplace.. - •,'
C use of Death... % .ercu.., �t 2. r�k/.de..l¢e ..Q_
Certificate was signed by ° �< M.D.
Address
..its �
Place of Burial (or Removal)
.
(If body is to be ten ril , fill in pace later)
Cemetery.. z Date of Burial ‘•',-JC , 9 19/I
(If body is to be temporarily he d, fill 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 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
Numbe d pn th basis eof EREBY GRANT A PERMIT
to m (. `-�.
the to hold temporarily and e body i
(LTn ker o pey yn having charg�e//of corpse) enter, •e r o erwi dis,)o Is to )
Dated / 19 " (Signed) ,""" (
Local Registrar f
This1/4 Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ject to i
meter or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is equire
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