Cothell, Harry Form VS.61. - NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tom' 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 CERTIrF�ICPn OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.....,✓..Sr`./.._.........
�y
Dist_ N(5' / County T we a ge '�.. j...,�
(If city, give street address)
Name of deceased
��mgle, marrie widowed
Se71 Colorie/1 ""c:- divorced (write t word) Date of �a �5— 19
Age 4 Years... / Months ( Days Birthplace...c'' "a'''�-� 1 �'`'e/
Cause of Death
Certificate was signed by ....4r M.D.
Address .. .... � '
Place of Burial (or t -..oval ....
(If body is to be tempos .�.eld er) •y' ' / ,� 19. 7 Cemetery r Date of Burial
(If body is to be .porarily held,fill space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the sat e appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have acce•ice':the same for re 'stratiori, ave recorded it in my Local Record with the abo a stated Registered
Number ,,I.V .n the bageie f I H£ RANT A PERMIT
to
a rasa)
the to hold temporarily and... . the body.
(U ranker or person having charge corpse) ... o e or othe se o e of[s how])
Dated f 1� ip 191 (Signed)
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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