Davignon, Lydia Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town;
Villa.e, 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. gistered No.
// Town
Dist. No�..(Gt . ountyViiinr
.aC
Or-Eity (If city,give street ad ss)
Name of deceased
'•, gle, married, widowed,
Sex;, u,.:Color .A,-. r divorced (writgthe-word).. . J Date of Death (i. 19.V...2
Age 9. Years Mo the 4-77 ays Bir place
Cause of Death 9.61 „_, „
Certificate was signed by ..,�r• ' `'' M.D.
Address ST•� �---,T... .e..
Place of Bu;lal (or Removal) / O"AN'fk. f
(If body is to be temporarily held, fill in space lot
Cemetery. .... Date of Burial / ` 19.E
43
(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 he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same for regis ation, have recorded it in my Local Record with the above stated Registered
Numbe d on the asis Hereof E BY GRANT A PERMIT etO Q.-4 ,-tw �
Name) .. rk�'�....,�"Y'4rY.4r ).(/� ..!♦r
the.. ... wR to hold temporarily d the body.
(Undertaker or kersn having charge of corpse) (Int rem?%12(
erwise disnose of[state how])
Dated....... J/ /' 19. .3 (Signed). ... .. . .. .. .. ....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crema n of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in ich case a Transit Permit (VS No. 62) is required.
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