Derway, Baby boy Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. 417
Dist. No
Tam2,-- .? .�/.l la.,d 1..County �� Zzi}}ege.. -�Ye--+ ,i(2;��,�z6i �
�, If city, give street address)
Name of deceased li ",,�Q.
Single, married, widow _,
Sex.. - Color...' or divorced (write the urd) .Date of D h .P7-, 19.Y.2
Age Yea, — ',1onth ... Days Birthplace.. ... ..... ....
Cause of Death... ...,,�.
Certificate was signed , M.D.
.
Address 9 -
Place of Burial (or Removal) ' ��,�/. ., �T �� �.
(If body Is to be temporari I Id,fill iAl:cej er)
Cemetery r'' ! '� • -, • !... . i.. .. - Date of Burial ,. ' ala_ 19.Yeg
(If body is to be temporarily held,fill In spac: ater)
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 ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on the basi tbrof I Y GRANT A PERMIT �� iiL�r�� --��
to ..
(N e) ress) ,.. .... ... ....
the ... ....to hold tempora ' and .e-4.,. •- -'(- Ahe od
(Un ie o rao a oving charge rpse) ter,remov th w nose of[ to how])
Dated ,, 19...4Lf (Signed) /
w, -focal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of ody ny part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Tra sit Permit (VS No. 62) is reauired.
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