Bernard, William Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
•
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 N .
��^^ , ( Tewa_ /
Dist. No.S( Q .County.l„�.J. . . i�}ag.... ?
dr,...,,,,A,
Or Cl (If city,give s reet address)
C, (\ ty 5...1
Name of deceased L/..��Jl ••,•... .k„•
/� 1", Single, maaried,_widewed
Se: .S—...ColorW.M.L�. ..�Qor divorced (write the wrd). &Je.. Date of Deat • i' 19... :•-
Age Years. /6 Monlis i i Days Birth lace. lad2S-a.. .h+4
Cause of Death
Certificate was signed by y(,Q�,, G,,yt,,, � h " M.D.
Address ,••. ..'��!R!.r�:.Xr/L1..
Place of Burial (or Removal)... '! .>Lt .,;�!,t.,I,.,Q, ,�y .• 7 v(p ,
(If body is to btW I fill s ace later) �" �1
Cemetery.:. . . .. . . .. Date of Burial.....1.12aGe.c ( 19., -2_
(If body is to be temporarily hel ,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 registration, have recorded it in my Local Record with the above stated Registered
tuber, and o e s' thery I H 151,3Y NT PERMI
... ....... . �,.... . , ��j � 1'i •
(Name). )
theto hold tempor • y and the body.
(U dertaker:rem eying charge of corpse) ter,re ove,pp��,�therw o [state h ])
Dated..... 19.. (Signed)........ : .1t
Local Registrar
This Permit is sufficient for the Removal (and Interment or do of a b to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a remit Permit (VS No. 62) is required.
S"-jv o o w a 'N v:c n 5.).E c a^o,o E n r,p 7. Fl , N w , < n o-••o.5 », p .Ito •,.:.
T� -. , , O'O•G.A <t C -ncr. .O a;W D"'..'f,+,° W P?f» G. '4 (9 N O O ?' �tC x�< roN ,,
P >3 a P3 � 8.-• A, � 0Wn''ywcm '?;8.0�2.vccm •w.0744, '• v,''.a;n.bw•mo t. a4nco, t`n% trrn rg. m Z
z: G"B`�'o .i n a.c•o n y < ,yo i-• ci p$ oa ro w 0
,ro a w o _ , c Gp, , s :•o'ury'..o'�c a- wn^'� R=; ` vn � w�o o ^;�s ,p w oA7xm o d
m �W Cn w 7< * � � � p�- y W 7 a � n V^n , n c �73 n •, � , N'Q w �V5.1
4 0o a v "' 0
5. m m F E_, n s:',3 O O .'^i ,. g N w • N O -, n.< E.•g• n's —g, °o < G.^ ^ O N 5.a.s.N y tr,a ^a m
l-, V O v
ti {-x o n G° �% 9° a•0, n c w._g 3 0 *?:n o N o ,-^ S.c E•Gg N o•(< t ° '0 k r -�..a
a w t:ioittttu
n ao'. WOo-- n. rz.. .,-2 a.aNmn O ,Sao »„C�1 a, a•�a •eaF0.C. CN .°.,waCr_. C•p n.,n7T7 0in , aO = 7, ANoyTOao•CHQ.V� �" �q 'OMO
a .,wG , = F•w'" :;? f9a.5 -6wno ?rioi Ean0 NRGNo - 7ny :N O Ca <�» m talLA ITI
j5'� 5'�w 7wC-. y o .n1 ig o cm'o �.:P-g-�g'x g^ni w sr C .F'g*MN ° w K7 S^ trl0 '1 + . ^ 30
o'n w o n+ E g "^5 , �c 9 n1 0-»^ n w w a o.-new a' '1 < m M
p .-I 2.••-j n p.
r •»C °.- ° n n N "' o c n N -•n a o y ° ' R rJ a .5 "'i,rt"°Y o ,o� -„`r�- •
•" •7 �Z CPI
a. 0., Q .`.t .-.N '^t' �_w K .~..w w r'.'� 'o w a..n (C„ "�, .95D N 1 G- , �7 FI 6' '�A.a A
,m, -0 rA'ni °,-.0 , � =R o . r, g - allow 04 .-; ! t '
5. a., �, o to/\
w -,tn 5 c a,.1,4 5. o �=•'.w c•5 (o'o .f°, p 0 n ' 5•5 "6..o=ci - w 8 y.�� N -•r.,j l Z -�
5D^' tn0 E � ° °' ;•� A N � 51, n`<w �„, ,' o v, w_,w.io A N y wee n `^ N 9 � �,y ! m '+7�1a ^ ` ; >=0
,tw sio5bo'=� 5� � awo -`oi » � ��•`' �nww o =o� n �°fD� co , aw�, G�T-� � ri grEoa' w .A. '74"'m
••.n.T,a• n a.,T40 to , 0.nnE N n w O, , n n So m 'm `Z Pri
° rn>oo so- y n w n ° ° ,a o n n R'e o f y o <.d , E•7�n a°N.G,o< �.~ x c.� m r_.•, o • = `M,,-,m
22..
z 3 n so sw n .T_t " -e < o o < o n n o n a G o , o r� 'flm a ,: Crl
v EA 0 n ct�o ,w, - , n F. : .= p'O `4•o,o a.w•P� a Gb �ti �....,anw , rs3 < a'0 4°'y 4.X0 ° 3: " v m`A
m , . '°. 5.. , .R~. Y..1 N n Np"c'c' »° 0.r•' 8 .n^ , 5-n n .ny C « M A a" ^ 1��
P. <i g w'E n O g ,'N Q O O .n1 , so �. -n GN•a n O, e n f,q '^GE p• .m O «•a' o • V. .O�
t ,i t17 E .n. �.x.n N 'n)• N'--Eva 0-y' , O F�.a 2 n G N , _.C ' g N • Cl) R -i a '" ''' \ .c.
o•m C7" n ° n� Cr r. N-:, a , `0 H o o ..., ,; ?•o a o ...E g .°c - r,• R n •G w • "�
m , B..' • , • _..y aG :'*n p n O ry a G..CO A a „ 7
a QOm ,< , �gn o ^y.3 .,-� G0 ° u, .. ° p.ow.�'� n R. + f95N � 10, Caa w ?r((.��. m ��im ""iZ
"o'fiCr<' �' o "� ° wo °^ '0 5'�� - o'ti� y~oNO5nw `G° 3'E2p) 0 q'g'''s' tJ� ' ..„x „ .` \ E�
N O ,
a Eam c $, Nr,8 = a5no., NNo- o•=.t. o ,-0 _„ N0m4 ,....105'.•-owro0M, ; etg xm� P n
a •Xw w N '.Nnn n w n ° .G n.d N < M c , �'
o w - ° ov w o sc.n , o n o o , y oU
tn» nb = orr, r, .1 Zro0s oga, Go-^ w -,,o nywJt nihrI
c CoU"re p .n1wZ ?• .=wo,-.o59,,, �,? O , 0y _an + Nwo ^^C x.. ».., 5 n o 'w N , w_. G p , ,a a,,_ a;'1 w s n' G)
�� `° �s�.an 'n*0� � 5 E ° p 5'-c N o >C�ro, o 0 . -4.0 -z-•o . , =,4 M �'. �, Ci7
-, � � ° pc ° Nsn ° < O ' Pc,- ~ =0 , 7 3 �N ° n '+ nGo.� wp " onn4 �aQ co
N F, n.c ., a v_, N y .w <- B c n .J a- �•o 5 o n m b
.� . . cy wn aye •' 5 a'NEa< i ••° ?)- 0 <7;6 p ((+ .," i\�' O
:a.m. -6., w� n64N oNa'.. , nMN Ana 5� V � r.0.1..oaRw to .�, 3af1D v�.