Monty, Melissa Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Gar 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 CERTIEIC, E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Re istered No.....d.
Town
Dist. NE �G 4 i County �- Village f
,S
ity (If city., gi e street address)
Nime of deceased --!/ ., ` `t,
�i/ SrhA4c, married, widowed, 7 �a�,
Se ll Col or.clvor -(writ the word) Date of Death/ �' /6' 19,E
Age GP..�r Years.... Months a s Birthplace.! O 2444s.u. J'..1.
Cause of Death �� • ,.�r- �^ -s -7't''-' •
Certificate was signe by /J, 'OR-a."'
•1`•
Address y-. r --AL
Place of Btuial (or Removal) (.#ar,-0.\ .. ..
(If body is to be temyf iy held,fill ins ace later) �j�,� 19c/�
Cemetery G//.... .. Date of Burial.I,�� •••r••••.----r.. T
(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 he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have cepted the same for egistration, have recorded it in my Local Record with the above stated Registeredtere
Numbe and on h:/•a ' eof It HEREBY GRANT A PERMIT! ' .. i
to %�/ % a,I: 1 (A
the .L .../" .... ... ..� to hold temporarily a the body.
(Undertaker or person having charge of corpse move,or ose o! how])
Dated , -r"..../..Z- 19.'2. (Signed).. rwis ....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Stet (subject to local
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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