La May, Judith Form V .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. Registered No. /Q 6
Dist. No., Al..County Cl c..4...e orc.l iliage... ��.f�
(If city, give street address)
Name of deceased .Aal-City :.. 2-1117 ,
vv��� Single, ma ried, widowed,
Sex Color..s.. 1• or divorced (write e word).,,, . Date of D t ... :r. 1a
Age Y ars Days Birthplace... .�
Cause of Death ..:elizths
! dv. ._.4 m.2.a.44/.4.4+ .. .
Certificate was signed by - - LD._
Address e..,..rv.
Place of Burial (or Removal)....
(If body Is to be temyyt�Arily ld 11 in use later)
Cemetery..., ,1�/1... Date f Burial 7 19.,3.I
(If body is to be temporarily e , 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 registrati n, have recorded it in my Local ecord with the above stated Registered
Number, a on the basi t f GRANT A PERMIT
m — ddress)
the to hold temporarily and .. t body.
(U, aker or pals h97pg charge o rpse) // er, ,or otherwise os (state hoc
Dated.... ' .! 19. ' (Signed) �y
Local Registrar
This 'ermit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sub' ct to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is r quired.
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