Liebiro, Oliver Form Vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 !? BLACK INK. �`�= %M4 'iatered No.
(( - -Town—
Dist. No ��County. 112./ Village--- ,!...e, .y4
r ity a str addr •s)
Name of deceased . . .ee41C..G/
i `'� � Sing e, married, widowed,
Sex olor... ... or divorced (write th word) 44-W.,-.. .Date o .. s�� 19
Age ... ,/.Years the Days birthplace. d T �•4;
Cause o Death .. ...
Certificate was signed b ' ,: . *-1 0- ...� M.D.
Address / '
Place of Burial r Remo 1)... .(/ (7'
(If body Is to be por fiLIl in ce /
Cemetery -- - ..__ T..f Date of Burial .... 19'"
(If body Is to be emporarily held,fill In space later) //
The Certificate of Death containing the a oye'stated particulars, having been prese to me, after careful exami-
nation, the same appearing to.be COMPLETE, CORRECT, AND SATISFACTO AS REQUIRED BY LAW,
I have accepted the same for registration, hpve record it in my Local-- yh the above stated Registered
Number, and on th b i 911-. E: GRANT PERMIT ( -- --
to �� ,/' �
(L'nd p on ving charge bf rp I _ �K/ // 1
(N +LCa�L
the .. .. se) .;...to hold tempo arr ily and..► �w_� the body.
... or th rwl oose of (state how
Dated 19......... (Signed) . ...RR'
�
L a eglstrar
This Perini is sufficient for the Removal (and Interment or Cremation) of a y to any part of th fate (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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