Du Four, Joseph Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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.
�f Tawu. �j�
Dist. No-674i�a County k2-4 Village Q'��% .r
//�� lty If cit` give street address)
Mime of deceased L,�/ • -- '
�yy, Ingle, married, widowed,
Sex ��/ ' olor �' or divorced (write the word) . .... . .Date of De th... .. J 9
Age 4 7 Ye s S Months.... . Days it hplace
•
Cause of Death •
•
Certificate was signed by ... M.D.
Address
Place of Burial (► Rem al) . .. .h. ,
.. . . . .....
(If body is to be to.,' :rily in ep e later)
Cemetery.... /,°• Date of Burial a .19.42,;
(If body is to be temporarily held. 1 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 have accepted the same fo registration have recorded it in my Local ecord with the above stated Registered
Numb et don the asis reof HERBY GRANT A PERMIT vs .• 4,
(A
the to hold temporari and the body.
(Lltaker or person badin charge� 9�s�rpse) ter • .
Dated.. ... . . .. . ..�.f.�.719.P2 (Signed)
Local Registrar
This Permit is 'sufficient for the Removal (and Interment or Crematio of a b y to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
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