Hillis, Belle 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. /9
Registered No
�j� T'awn
Dist. No.r.r6 0/ County �/ . .. Village
E' (If y,give street address)
Name of deceased
Single, married, widowed,
Sex..,.t Color.• or divorced (write the word).. .Date of each. . c2 l 19./ir?
Age Yea Months ems— Days Bi hplace
Cause of Death -• 4i
Certificate was signed by �� M.D.
Address n ..
J
Place of Burial r Removal) .�:... ..
(If body Is to be t rari]y held,Gil ins ater) �� ,
Cemetery , ... . Q,.�— . Date of Burial • .c- V 19T/e+�
(If body 1s to be temporarily held 1 in space later)
The Certificate of Death ontaining 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
Number, an the bas' tlof jRANT A PERMIT
�O
to % �j"' ,r/4
(Na (Address)
the hold temporar' nd. t e body.
(Uncle r or person av g charge o c rpse) , e ove,oy atrw�i e d state how
Dated 4�� ,. `f 19ge o (Signed) SrC�
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Tr resit Permit (VS No. 62) is required.
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