Prevost, Roland Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ozr 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. Registered No.
Town n /?
Dist. No..1.4 0 County Village
or,city (If city,give street address)
Name of deceased i .... . . . ✓.49-1.> r el-e4'°—`77
ingle, married, widowed,
Sex �y.1,44 Color.... r divorced (write the word)...,4-7-z-taC. Date ofy�ath.,•^� `- 19.f
Age a Years ont /,7 Days birthplace.... �- t,�
Cause of Death........ _ � � ,t
Certificate was signed by !� �r��,. . .... i- M.D.
Address 7 2. 7
r
Place of Burial (or Removal)... ... ,, _
(If body is to be i,,`,orarily field,fdl in space later)
Cemetery e • a,.4e-- ct.-.ter a .� '���� / Date of Burial. 19.
(If body is to be temporarily eld,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 Regi tered
Nu er, and the ba 's t �EREBY GRANT A PERMIT , � J
.-y ( i4e) (Address)
the <i �PR et„,
to hold temporarily and the body.
rert� er or_person having charge ioj corpse) --i (Inter,re ove-9r otherwise I pose of [state how])
Dated i -5 19....Z..� (Signed) -� v,.AP
L al Registrar •
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to 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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