Dalton, James 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 No.
f Town �+u c[�f
Dist. No County Village Slu.f7 L,1.�1 ..�, A(j�} ..L
(---.. or Cit e . .,,,O (If ci street address)
Name of dec ased o�L
// ? Single, mar , widowed, I l/
Sex.. .. . .. .... lor6LI.�� divorc write the word . Date of D th... l ..19. T.�
Age/ Years a., Months Days Birth lace... . ..
g y p �,,
Cause of Death ,,,,,,,,,,,,,
Certificate was signed by :).'Y.1 M.:.. - ,y,., --
,<...33..4. .... . . .. : :H NEST
Address r ,
Place of Burial (or Removal)
. . .... .... . .. ..
(If body is to be temporarily held SU in sp later) L i (/
Cemetery C.42141 Date of Burial.... ... .. 17 19 y
(If body is to be temporarily held,fl11 in space laj r)
The Certificate of Death containing k e above stated particulars, having been present 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
Number and the basis thereof_I EREBY GRANT A PERMIT -
to -) l t
41111*Ve� 2 ddress)
the to hol emporarily and.. the body.
( dertaker or p on having charge of corpse) ter,rem v or o erwi e dispose of[ e how )
Dated... ,...2.) 19...SI. . � (Signed) - 6A,/ - �.�....
Local istrastrar -
This ermit is sufficient for the Removal (and Interment or Cremation) of a body to any art of the StaF9' (subje `to cal
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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