La Rich, Narea Form V . 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No..._..._...._._.
r r '/� Town
Dist. NC v JCounty 11eri . ,.t Villag
, Or Cl (IE city,give a t address) •
Name of deceased/2.,�A,, _ _/�1 ��..-. L p
,, t Ingle, married, widowed, \
Sex 4olorlkL/. :a. divorced (write the word) 0. ..Date of Death. ..- 7 19./0
Age 1 Y .. Months. Days irthplace... ;
Cause of Death.. L�,C,f�41C �.e<
Certificate was sig J2ty. .. M.D.
Address... .. . . . . ..
,,..1` G�
Place of Burial (or Removal).,. ,,,
(If body is to be mporaril'held, fill In space later) a
Cemetery.... . Date of Burrc2lJ 19. t0'
(If body is to be temporarily h ,1111 in space later)
The Certificate of Dea 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 stated Registered
Numb r, and o t ,,,basi hereof I HEREBY GRANT A PERMIT
to ... . ,[ !/
(• ) (Address)
the to hold tempora/'�y and. .nd... ... . . .. the body.
'nde J0erson having charge of corpse) 14�=�Iran ter�tnov r otherwise dispose of [state howl)
Dat . 19�/s. * (Signed) 1�
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (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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