Churchill, Howard Form VS.61. NEW FORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Lr 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.
Town
Dist. No S ` County f 4:44.6-4,-4---
. Village........t ( tr Or Clty sit ive street addrName of deceased (� Q.•$Single, married, widowed, o` fjSex.. 4 •-Color ^4�Tor divorced (write the word)wA+�' 'q Date of Death —4 -- 1-19• ,
Age....JLS. Years k Months ?-0 Days Birthplace
Cause of Death..,. . ...t � /� --
Certificate was signed by t:.� . . —" .
M.D.
Address ,�
Place of Burial (or Removal) p.,.c,iie.c„ 1. ` 1.
(If body is to be temporarily held,fill in space later) �
Cemetery Date of Burial 19.SF1.
(If body is to be temporarily held, Jill 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 be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have record-d it in my Local Record with the above stated Registered
Nu er, and n thyj,basis th eof I HEREBY GRANT A PERMIT
to A 3--`a—,/
ame) ddress)
the. s to hold temporarily nd the body.
nd t or person having charge of corpse) ter or o erwise dispose of[state how])
Dated.. ... ./4' 19 tf3 (Signed).;
,... .. .,
Local Registrar
This Permit is sufficient for the Removal (and Interment or re ':' on��f a body to any part of the State (subject to local
emetery or other regulations), unless removal is by common carrier fin wit' . case a Transit Permit (VS No. 62) is required.
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