Carpenter, Russell Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT •
it2r 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 occadrred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFI T)OF
DEATH, LEGIBLY WRITTEN IN DUR BLACK INK. e stered No.
� / Town
Dist. Ncia ( County.... y Village. .. ,
• ! or C. cal' give street add ssr�� )
Name of deceased J •
Se3�0�,/ /,/ Single, married, widowed, �t,
' Color4C� or divorced (write t wor ) Date of D h / 1950
Age 7' Ye s.... .Y Mo hs....... ... ays it place.. .. . ... � 7
Cause of Death..
Certificate was signed b . .. • M.D.
Address ,t �,
Place of Burial (or Re val) ---2"'�--.
(If body is to be temporar' eld,till in e later)
Cemetery.. .... L/.,4r4e-fet,' Date of Burial.... /d 19 3
(If body is to be temporarily held,lilt to 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 ac '-d the same ation, have recorded it in my Local Record with the above stated Registered
Number .� � j a EB NT A PERMIT
to
the........... . .... . .... to hold temporarily and 98) the bo y.
(Und,/.er o ,•'- :o7ing charge pse) ` or otherwise disn f[ e howl)
Dated 1.... . .. 19. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject t 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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