Hoag, Mary Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subreaistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICAXE,
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Re istered No.
(!L� VillTrrwrr-
Dist. No County.. .... .. . age /O al9 Ite31.
' o t (If city,give street address)
Name of eZ
:0.`�
Single, mar ' d, widow , /0,
Se .,�r?A... r _ar divorced (wr:te the .. �7 ' 19...4�
Age ~.7 fear- S Months,, i Days Birthplace...
Cause of Death..... '�
Certificate was signed by . ..... .. .. .. ... ...+C. ..R ,�._. M.D.
Address /'
Place of Burial (off; . oval 01-6-65 -7.A-'
(If body is to be temp,.l r hel i c er)
Cemetery !''./ ' Date of Buria 61L19„..C/ 7 19. .
(If body is to b• emporarily held, ill n space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, th- me appearing to be COMP ETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have a �ed the sam,or r str ' 1, have recorded it in my Lo ecord with the above stated Registered
Number, ;y e t f E �' GRANT A PERMIT
to .... . •
.. .. .... ... ... .
the to hold temporarily and the y.
(Un • o ing charg o se rpse) (In ove r oth rwi nose o e how]
Dated lI 19. (Signed)....
Local Registrar
This Permit is suffi lent for the Removal (and Interment or Cremation) of a body to any part of the State (subje 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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