Barney, 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 CERTI,EICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. -" .e.711.
Town / r
Dist. NoJ sQ County `; ?hh.y �/ Village /4.... !��
-m'1✓lty (If city,give street address)
Name of deceased
Single, marrie idowed,
Sex • Color..%,,V1..- or divorced (writ he word). Date of Deat -,7a 9 ,
Age 7r Years .. .. M the Days Birthplace '
Cause of Death : ?/
.r/ .
e as signed-by --. __-
Address a2: b..... .. .., 2�' •
Place of Bui ial (or oval) . �/
(If body Is to be tempor .1 held, i sp a later
Cemetery .. . ...,- . .. . .. Date of Burial ....l?..c3 193..2
(If body is to be temporarily held,811 11;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 he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the abo e stated Registered
Number n on the ba 's er�^�ry I HE Y NT PERMIT lZ,
(Ad
the o bold temporar' and • h .
the ov.
Wad er or rso a 'ng charge of pee) er,re ove,o hera se of[state how )
Dated. .. .... . o 19..7 < (Signed) ...... ... ... .. .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cr atio of a to any part of the State (subject to local
cemetery or other regulations). unless removal is by common carrier, in which case ransit Permit (VS No. 62) is required.
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