Gleason, Clifford Form VS.61. -VIEW YORK STATE 4PARTMENT OF HEALTH
OFFICIAL BURIAL :(OR REMOVAL) PERMIT
der This Permit can be signed only by the Local Registr ar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred atter the FIVING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DUR E BLACK INK.; Registered No.
O/ Town
Dist. No (�. /...County Village. ,
116C--2*-
Or City (If city,give street add s)
Name of deceased • • •
�i/ , , married, widowed,
Seh^fir 4!`4 Color L(/ divorced (w to tl:e word) Date of D 19. E
Age Y e Months.. - Days firth ac ;:,,���
g � O fitCause of Death e •••
Certifri_�(c -�ti.�:-sigiied b4.... ... .i' .. . .... . .. - _ — M.D.
Address i Place of Burial (or Removal) y
(If body Is to bet aid,fill i cel
Cemetery ac -• .. .. Date of Burial �/ 19 .-T.
(If body is to be temporarily held,fill n space later)
The Certificate of Death containing the above itated particulars, having been presented to me, after careful exami-
nation, the sam: ppearing to be COMP ETE CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accept-;�e same for egist .4e, K. - •ecorded it in my Local ec with th ov ted Registered
Number, an •n the ..si ., CANT A PERMIT
to ;,�
N:, ! , re s
the �� to holt_ temporarily a d e body.
(Un.•. el ersonr ving cbargei pse) (Int ve rot ads no [state ho
Dated ,✓„,e. /� 19... (Sign d)
Local Registrar
This Permit is sufficient for the Removal (and Interment it Cremation) of a body to any part of the State (sub•ect to local
cemetery or other regulations),unless removal is by common crier,in which case a Transit Permit (VS No. 62) is required.