Bartlett, Gertrude Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ts- This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town:
Village, or City)41 which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF$5A3'E Of
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. ��
Tow,1 .
Dist. Na� �6 �� County t '�,.. V•ifiage a
80. lty (If city, give street address)
Nime of deceased
Se7,,,n� Single, married, widowed, r:/ .a
6.71 ' Coloi/l4 or divorced (write the word) Date of D a ,e'6'" ;,.,.i r 19 513
Age 7/ Yea /0 Months Dots Birthplaf�...r% `�G% 4 `�2 y
Cause of Death 'a !rC... . �`/ ....t..,li
Certificate was sign'e "'+ M.D
Address 7, iiik •
Place of Burial (or : oval) "-`- .
(If body is to be telmp, held fill i ce]a er Q �1 ,
Cemetery . ate of Burial A 19 `3
(II body is to be ten rarily 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 accep Sid the sam: for re • trat-i.n,,,`. e recorded it in my Local Record with the ab ye stated Re istered
No umber, a on-th b,;�f eof /�. :Y GRANT A PERN�I /-- ��
� � ,,, ,,,/ bess)
the ���=ti4�� /j��1 to hold temporarily and. , the body.
(Under er erso baying charge o c)rpse) n e,or other> se Be f Es e ow])
Dated. ,.. . . -.'.4 19.. .T (Signed) 4- .
Local Registrar
This Perb►it is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Stat (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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