Dary, Peter Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
_ OFFICIAL BURIAL (OR REMOVAL) PERMIT
lor 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 alter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFACKU OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. ci4. _._.
Town. � �
Dist. No 74.0..County (---2/ . . age.C. /._—. . ...I/ f4e.47-4.f ?,. y.
��[[
or City (If city,give street address)
Name of deceased..ate .../4, 4-i,
Single, married/widowed, .
1416
Sex. �* Color , (.ivorce(i -.ur is the word). Date of D th. sa...19. ,3
Age....rsr 'Vilars� i �� A 'Months'. / Days ' , Bi place y
Cause of Death./.'! ;!!era . :�� ��� .tom � ��Certificate was sin ( by.... .. M.D.
Address... ..yam.. ...... .... .
Place of Burial (or Removal)......�. 1....
....44..e..4.44...4.1
. . . . ........
(If body is to bpiem rarily eld,Jill in space la r)
Cemetery. '/
Date of Burial... . . 19...7`;
(If body is to be tempo rily held, fill in space later)
The Certificate of Death containing the above st ted 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
N ber, and pp basis t reof�1[ iEREBY GRANT A PERM
.... , ,T:zei, 2med./7-z-t-i-
. k(A ress)
the to hold temporarily a the body.
ertaker ) (I remove,other di nos 1[state bow])
Dated. / 19.a -3 (Signed) C
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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