Bennett, Charles Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
VT This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (To ,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERT ff F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No....
Dist. No /.County.,..IN /�....V' age
Name of deceased
�� .<<Y.. . .. ity f ity,give street a 1 dress)
,j11,6 Single, married, widowed,
SexColora./ e- divorced (write h�word) Date of a 19.-1.
Age ? Y• ,g, Months. Day B' hplace
Cause of Death...... .. .. . .:>....
Certificate was signe by 714- ' M.D.
Address i.......... .. ... '....
Place of Burial (er Remova ..... ....
(If body is to be to fill ins later) �')�' 19 ��
Cemetery ,,...., Date of Burial �/
(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, th- same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have J
.ted the s. e • r" ation, have recorded it in my Lo cord with the above stated Registered
Numbe •e j a ' / �EBY GRANT A PERMI ..e.
the / "... ' �� to hold temporarily and ss) the body.
(Undet,i er or pe n having charge of corpse) // t ove,or of wis snore o e how])
Dated ...e.e.,......, 19.)$.9 (Signed). �Z/ •' 4�• ••
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the S to (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 2) is required.
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