Hart, Odille Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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. .9 D
47
Dist. No Ql.County 1...7�I..l244—e7 .kii .... .... .. .. -4
�V�9!'City (If city,give street address)
Name of deceased
nn � Single, married, widowed, ,,(
Sex.... . olor.%I4' ..or divorced (wri the word Date of t :.. , 1 19- a..
Age G...e1 Years.... M the .. Days B•rthplace...
Cause of Death•..a0 42..-.. ,,•- -- •-
24,49.14~0:egeett—' ..0'(
Ceertificate was signed by . ee,"--- M•
Address if t '
7.
Place of Bul ial (or oval)
(If body is to be temp ar held, fi s ce late ''11
Cemetery.... . Date of Burial O..e../••J,7 19••,Ta
(If body is to be temporarily held, fill in s ce 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 acce d the same for r •stration, have recorded it in my Local Record with the above stated Registered
Number, on the b is th f I EBY GRANT A PERMIT '
•
( :,dr•ss)
the .. . . . .to hold temporarily and... ' de .�' . r body.
(Und r or raog�av g charge orpae) .nter�/�./- •o .. wi /is,). : ;•/��
Dated .,.,/ -.Crf...f� 19. (Signed) / .. . .. .. ..
� _ Local Registrar
This Permit is sufficient for the Removal (and Interment or C e a.--":"--- o a".o to any part of the State (su•Sect to local
emetery or other regulations), unless removal is by common carrier, in w ich case ransit Permit (VS No. 62) is equired.
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