Harris, Ada Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ca" 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.
/�
�TT — Town.. 1/"
Dist. No '1�GG. County. . Village .. e..
(If.city,g e street address)
Name of deceased../ 71�1/lt.... ..r04 tiv
Single, married, widowed,
Sex /� C��olor .....o divorced (write e ord Date each ./. ...19.1'
Age • 4. £.Years.. .. .... Months.., �`- 7 .Days Birt lace ... ..,2-
Cause of Death
Certificate was signed b .... ... . .. . C / M.D.
Address
Place of Bub;ial r Removal) ... ...CFCit- ''1'c..,. /,� , '///Ig- 7
(If body is to et porar:] eld,fill in space later) i"/I��i���/ 1 19 ��
Cemetery.. Date of Burials"(
(If body is to be temporarily d,ell in space later)
The Certificate of Dea 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 re 'stration, have recorded it in my L 1 Record with the above stated Registered
Nu and on bas ,,he I =RANT A PERMI , filux.ie C7" 4, /7,,,
to
(Name) (Address)
the to hold temporarily a (/ the body.
Dateddertaker pereyn�faviag charge f pee) (Inter,remove, erwise dis � e [eta howl)
. /..[� 19. (Signed) . ..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo t'o any part of the Stide (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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