Cavanaugh, Mary —form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. .4.1 ?
�,� Town / c2.... �
Dist. No�`To Q/ County �/L�/s;.d �7 Village .CP.... .. .. .
eit,� :„; Or Clt If city,give street address)
N.ime of deceased7. (\/Ly/(.�
� � ` Single, marr , widowed, �9
Sex.7. .. ..Color.A.21 . or divorced (wri he word Date of D th .19.. E
Age // Yee:* Days Birthplace...: �f�• •mi •
C use of Death �.. _ __e„'4t
Certificate was signed by =— --4 � /
:. :... , I.D
Address .... . . .. C�..
Place of Bui ial (or mov
(If body 1s to be tern ,ly he I p 1 r)
Cemetery.... - Date of Burial. . ... 19.
(If body is to be temporarily held, 11 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 RR ord with the abo e stated Registered
Num don th sis,Nly�reof R Y A A PERMITLi.
ess
the to hold temporarily and A" e ody.
(L e or..ger9bir h 'n Q charge orpse) / / , re ,or herw s,io tate h�./)
Dated 4,/- Q�. / 19.`. (Signed) #I �:�Gl„w!�G�7 �for .. ,---
Local Registrar
\ -=s Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s .ject to local
.y or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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