Minor, Emery Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. 7.____._...
1 ` Town
Dist, No.3.242.,County..'.. Q Vfltage t-- --C-
r or City ' (If city,give stf dress)
. �
Name of deceased .. .. .. . %et..�.ezcpa....t�. � a.....` )
Single, arried, widowed, 19 y1
Sex . - Color- ' or divorced (write the word).'.... Date of
Age Fears `� onths Days Birthplace. :, ,c;`Y
Cause of Death si F4 .;....c.�¢s.el.,e..:: e.a.. o... .td40.!-S-<*44
Certificate was signed by sez:e.e4--1 M.D.
Address . .... , r. ry
Place of Burial (or Removal) .... . ..
(If body is to emporarily held,fill in space later)
Cemetery.. - - /--,L d "% -,./ Date of Burial Z 1 19..43
(If body is to be temporarily held,till in space later)' vvly
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 for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis ereof I HEREBY GRANT A PERMIT
to 1 .�. ... Name\ ` (Address) / ` !
the '"�~z�'�- ' to hold temporarily and {" h the body.
(Undertaker or person having charge of corpse) (Inter,remov or ofperwise dispse of[state how])
Dated '-.....1..y 19...:.3. (Signed) ,: h..; - -..-l---..
4�j, d Beal 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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