De March, Alice Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
s2r 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 _.-
/ Town
Dist. N$..IA i TCounty '24". Viiinge
(If city,give sir address)
Name of deceased
Single, married, widowed,
Sex � Color.Qi.(J....... . ..or divorced (wri�jje the word) ' " Date of Deat .. .. ... /� 9' (�
Age ff.& Years 0— Months •:A.3 'lays Birthplace. .. ........ ... 1• <4-•4-+.-,1
Cause of Death ..t5Urg,.,re.Q' `� 4z. ,..) / , ►
Certificate was signed by -. l// M.D.
Address y
Place of Burial (or Removal) . ... TJ •••• /
(If body is to be temporarily held, fill in space later) � t
Cemetery ‘ X I t Date of Buri .. 19. Z
(If body is to be temporarily held, fill in space later)
The Certificate of Death con+;,.ining the above stated particulars, having been resent to me, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acc pted the same for r 'stration, have recorded it in my Local Recordn with the above stated Registered
Numbnd o the b ' th f I HEREBY GRANT A PERMIT W
�.tW A-- --
e
to t
me) Add
ress)
the J..��/1/1- to hold temporarily and the body.
dertaker person acing charge of corpse) (In r ve,or otherwise moss of[state how])
Dated... ... �.Z.. 19..S ..Z. (Signed)... .. .<.�,.�2*� •�•••?:
Local Registrar
h' Permit ' sufficient for the Removal (and Interment or r a ion f a body to any part of the State (subject to local
cemetery or othe regulations),unless removal is by common carrier, n whi case a Transit Permit (VS No. 62) is required.
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