Hammond, James Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
11}9-'This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District (TownVillage,or City) in which the death occurred after the FILING and acceptance of a COR-
RECT AND CO LITEE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK'INK.
Dist.No.......... ID ... ,o0 rr'�, _``'' Registe d No may,
County....._.._..__.___-__ _.hllp[LfL411_._ ate of Death LA �',rf 19
Town Vil- ��� P 1
law,or City' '''+''�' "_..._ — Sex _ Age__` -D___Yrs. Color...4I��ii.—
(Cross out names n of applicable) n (Gr�pZ) f
Cause of Death ?lsa�` ^ t p?Lla ?.__.----____-_
`ace off Burl.— � 1_ . toy . _ 1_a-(tii._Date of Burial- ...2.i94
A CERTIFICATE OF DEATH of
(Givefull name of deceased
having been presented to me containing the above stated particulars,and,after careful examination,
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 abo a stated Register d N ber,and on the basis thereof I HEREBY GRANT AEPERMIT
to 5.i-adLl J.j .4------ , -_- ...g `t___—_J�_F eil. -1.1 :_.�.1.t13.ra(..1—11- _..,,
Na of n ak
the__________...... ,. . . to .., the body.
(Undertak �o ha. c rge of core (Ill emovc,or o rwi napo, [state howl
Dated %,[ --19 (Signed)- �.__
�] ocal Registrar
This Permit is au cient for the Removal (and Interment or Cremation�df a body to any part of the
State (subject to local cemetery or other regulations), provided,that where removal is by common carrier,
the above Permit must be included in the Transit Permit.
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