Hewitt, Robert Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itgr 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.
// l Town
Dist. Noi:�(�.6.7County `-"[�L.! i ag ,e( --
cp 0/L. - • (It city,give st address)
Name of deceased . ...
'' ? Single, married, widowed,
Sex Color or ivorced (write e word) Date ofath... y 19.40
Age 7 Years the s Birthplace
of Death err
... .. . .. . . .
Certificate was signed by .... .. ..... �... M.D.
Address
Place of Burial (or Removal) r
(If body is to be temporarily held,fill in ep e later) Z'C�
Cemetery A , e s. Date of Burial i 19.4e5-
(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, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW
I hav accepted the same for re 'stration, have recorded it in my Local Reco with the above stated Registered
Num , and on .4ftyEBY GRANT A PERMIT 9.12.cats.
the 47`--!1.. to hold temporarily and the body.
(Ua r rev g charg of rpue) Z#Unte •r= ve r o rwise dispose of[state how])
Dated 5.. ` L? 19..,,, (Signed) c.7 ....
'Jr',. iii veal Registrar
This Permit is sufficient for the Removal (and Interment or Cre ./tion •tea 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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