Chadwick, Charles Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Villa,e, 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. egistered No.
iiDist. No\2 4P.1 County Town vilinge.
di o City (If city, give str t a dress) •
Name of deceased C x .r4-,
c�, Single, married, widowed, ®®���� �j.,
Sex..Y° ( Color.I or divorced (write the word).�lilJ Ci: � Date of Death...11.(/.1. . ... ..19 19..Plc_.
Age. .. Years.... ....... Days , Birthplace
Cause of Death (.jenths
--- I.arv^--0-6_,!•.,.,.,. , .
Certificate was signed by M.D.
Address -.011.0171, 4 _(,),Z1,7if
Place of Burial (or Removal) pi.,-1,4ir--c.G
(If body is to be temporarily held in sp ce late
Cemetery. .... .. . in
Lo .... .Date of Burial G Q 19.�.5
(If body is to be temporarily held,till in space later) •
The Certificate of Death containing the above stated particul s, having been presented to e, 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 stated Registered
Nu r, and o e b is �e eof I HEREBY GRANT A PERMIT L2 `_ atyf1
( e) 7 C .dress) •.
the.. ... to hold temporarily and '`' the body.
ertaker or person having c arge of rpse) (Inte rem ve, r erwise dispose of [st,8te howj)
Dated. ... . :. ... .. iY 19..(.. t„ (Signed) 1 l r....... . L. I
„r Local Registrar
This Permit i sufficient for the Removal (and Interment or rem lion) a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, i 'whit case a Transit Permit (VS No. 62) is.required.
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