Wood, George Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
P' 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
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No i•C
/// Town /� p� -
Dist. No County /� �'`' Village /7 v (l '1��`
or 15 (If city,give street address)
Name of deceased
,���fI /// Single, rried, widowe
Se�:..,g/40-'' Color or divorced (write the word) Date of D 3 a 19K-3
Age 2 Years 3 Mon s �� D ys B' thplace ,A -e6
Cause of Death
—
.... . .... ..... .... . ..... .
Certificate was signed by.... ..... ...:.?`it,..t...�
M.D•
Address
Place of Burial (orfi moval ,I—'-' i
(If body is to be temp�0 �� hel Li 1 ter) '
Cemetery Date of urial 19.5
(If body is to be temporarily held,ill space later)
The Certificate of Death c aining the above stated particulars, having been pres ted to e, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accept he same for re • at' , h e recorded it in my Local Record with the above stated
Registered
Number, and the basis f RANT A PERMIT -
to ,. .... . .. . .
a e) ( dd se)
the to hold temporaril and.. the body.
.... . .
(Unc rtaker��.eraon hying chargggyyf orpae) ter remove,()remise e o [e o 1)
Dated * 46.-.:i 19.r.3 (Signed)
Local Registrar
Thi/ermit is/ufficient 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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