Shaver, Nelson Form VS.61. NEW FORK STATE DEPARTMENT OF HEALTH
. OFFICIAL BURIAL (OR REMOVAL) PERMIT
Aar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tow._,
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.
Dist. No. 4 S7 County....,(4j TownViftage,..
or City v (If city,give street address)
Name of deceased . .
Single, married, widowed, • -
Sex2f� Color.i or divorced (write the word) fP' Date of Death a-1'`' i 7 ^ 19 1 1'
Age 77 Years Months z l ays Birthplace
Cause of Death
Certificate was signed by -• • Mom,
Address lf'"6 . . .:.r `"1jam, / <: ..r "--7?-- ,_7...._
Place of Burial (or Removal) �,,,. ., ..��..�� `�.1 fe
(If body is to be temporarily held,fill in apace later)
Cemetery Date of Burial. .... 2"i... 19 y
(If body is to be temporarily held,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
et
Numb r, and on bad there I H BY ANT A PERMIT
e i esa)
the to hold temporarily and the body.
(Undertaker or erson hav �kharge of corpse) (In remof, air i ais fate how])
Dated ' ...2-' °` - 19.. ..7" (Signed) • ..a.vL'. " .. .. .. . .. ...
.4,,j ��, Local Registrar
This ermit is sufficient for the Removal (and Interment or Crematiolf. of a b::y to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in w. h cas- Transit Permit (VS No. 62) is required.
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