James, Elizabeth Form VS.81.` NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Pr 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 CERTIFICA1E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No sa ,
�fj TouF •
Dist. Noa.1' a( County i.."/C:e E .r11/ mill rge. ..
'�� O Clt If city, give street address)
Name of deceased G.ZeG.4,��C.-A �r2�..r ,r+2.�
j Sing , married, widowed, • /
Sex....C..7"-• Color. -. or divorced (write the word Date of D /� 19..'� -
Age Yea-s./.. Months Days Birthplace... ..6 ..•)tf•
Cause of Death..... .. .. .. .... (/
•
Certificate was signed by • - MIL
Address •
Place of Btu ial : Removal)
(If body is to be •m!, .r'ly•held, ii s ce Niter)
Cemetery..... . ...e,.. rGgr .....( .G.ad Date of Burial - j/ 19,f.�..?�
(If body is to be emporarily 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 ecord with the b ye stated Registered
Numb don th ba - t ereof EREB ANT A PERMIT
to saa,14 f.. ,.
m
the to hold temporarily and tie body.
( / aker r pe•son eying charge.o corpse) , i�I e ove,ocher d:,•,o tate how])
Dated... , .. 19..f (Signed) i/'���
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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