Heustis, George Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
22g' 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
Registered No.
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 77 1
/�� Town p�
Dist. No 4� County....l C!.. Vii}age.......2:./ `
or CI (I city, give street address)
Name of deceased
Q , m ried, w.ldnwed,
Se ae• Colo .. ... . . ...or-t ereed (write the word) . Date of Death.. 19X:'
Age 6-3 Years. .... ./.$2. onths G .Days Birthplace
Cause of Death / /
Certificate was signed by M.D.
efrAddress �. .. �.. .... -. M.D.
Place of Burial (orpal) � � 'G(If body is to be tempora ,Ml In space later Cemetery -e- fY'Date of Burial.. 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 COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for regis ' n ye r orded it in my Local Record with the above stated Registered
Number, apnn the s reo Y ANT A PERMIT
24
_ ,f
to ��i ^ D.0 ' - ar.e.oz /�' • .t y
ddress)
the to hold temporarily d the body.
(LT art or pgSon having charge o c rpse) ( remove,or gY.bvrwis s��ose of to how])
Dated 19.. (Signed) f/..r
Local Registrar
This Perm' is sufficient for the Removal (and Interment or Cremation) of a body to any part of the S to (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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