Millington, Florence Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
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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 DU LE BLACK INK. Registered No.
1 Town 1"." ^�iC�/
Dist. No `5 Z/County Village „AL
OT City . ,,give street address)
Name of deceased.....—..lI. .... • >f.. . ,.
? �� /�ESingle, married, widowed, •
• //� I z
Sex.. Color `'4�r divorced (write the word).. Date of ath A!'Y 4i./1.9
Age.......... 9P.Yea onMon s Days Birthplace ••
Cause of Death
Certificate was signed by.. - M.D.
Address ..
Place of 13ui ial (or Removal) .•
(If body is to be to o r;ly hel ,fill s ) ' /
Cemetery.. ..,, b
V
. Date of Burial.... -'°"1.p, f-o 19...
(If body Is to be temporarily held,Ell 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 SATISFACT RY AS REQUIRED BY LAW.
I have accepted the same for re is ration, have recorded it in my Lo Re r •th the above stet Registered
Nunbnd o Jieri r HF. EBY GRANT A PERMIT `c
(Name) (Address)
the to hold temporari y and ✓ the body.
(UnMrtaker or person havi or eng charge of ) (Inter, rem v ,or of dis'iose of a ow ) .,
Dated. . ,•,.L�:Q„r., .2- ,' 19. (Signed) / /
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( ject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is equired.
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