Vaughn, Robert h
Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tS 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 CERTIF .�E,OF
DEATH, LEGIBLY WRITTEN IN DU LE BLACK INK. �stered No. rf
Tee
Dist. No`5 L01 County... ... Village. / "�"�`�
or Cit (Jr city, give street addr s)
Nime of deceased �.. ..
��yj_/ Single, marrie idowed, �f�� /p
Sex .. . ....Color or divorced (writ t e word)... Date of 4 19.K
Age f Years P .A1 hs... ....l .Da Birthplace +l yaG 4/ �r
Cause of Death �.y �t G
Certificate was signed b}/ `J M.D.
Address
Place of Burial (or R ovalj ... ... �* - ore
..
•(If body is to be tempor r .�`. later) �} /�
Cemetery .. ... . .. .... .. � Date of Burial �C7 1L� �`� 19. ...
(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 COMPLE E, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accep d the same f r r 'stration, ee recordedr 't •'' y Local Record the abov stat�,d Registered
Number, neb h 'f I HER 'i`J, �;:� IT /Jt0 4 �"'�'�
4.4e
.. N es )the (hold temporaril an ..the body.
(Lnd�e�av�er oIr pars .b ving charge,�oyycorpse) (I emove,or oche se of to o ])
Dated. ....IG!`�'� 19..9 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State 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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