Wiley, Anna Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itr This Permit can be signed only by the Lc.-al 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 gE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. a
��a!'4.,e i'e" Town /
Dist. No.S�Q� County �}-ge •„ ,
pr-("�y city, give str add so`�
Name of deceased ,,•�j"/�~��� /
Single, married, widowed,
Sex Color.. or divorced (write the word)�,� Date of Deat 19.
Age Y rs.
?:(9 ... ...1/ o the '
a�. p .Days Birthplace.... �...'ICause ofath.. •
.. .. .. • . . . ... .. .. . . . G e >G
Certificate was signed by M.D.
Address Gei- ..,... 1. ,....
Place of Bu;;al (or Removal)
(If body 1s to be to 1}c held,fil ace later) - , /
Cemetery.. ... i4-2.- .Pe ... Date of Burial...... .G2 .3.--- 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 registration, have recorded it in my Local Record with the above statedst Registered
Number, a on the basis tl of rR GRANT A PERMIT %*�_�G.x?
•,‘ 77. 7%
(Nam (Add s)
the to hold tempor • y"and the body.
(Un er or perso hav' g charge gexSgpse) (Inter, move,y�reeph�er ise oae of(eta ow])
Dated. .....,. 19...1'4 (Signed).... 4-4.....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
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