John, Marie Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
six 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 CERTI s DI
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. /` Registered�is- No.
Dist. No vo/ County ..LA f� Vi}li e /i #a -/ �r4,--4.ii.
/ y (If city,give street address)
Name of deceased ,•G� ..,.
sr t
GrA. . ... ... . . .
-/ Single, married, widowed, xif.
Sex. ..Color irAl•� .or divorced (write the word).. .. Date of i��.404A .. 19/4j
Age t(i Year a In the Days place ''� tGL4.4.. �.
Cause of Death.... . .. .. . .1
- Certificate was signed by . �l 11�.D
Address griCGv,,,, ,,,, ,,
Place of Burial (or RemovaI)."
(If body is to bexpporar 1y h d, 1 in space later) �
Cemetery ate of Burial.... 7_i /
195i,1
(If body Is to be temporari held, fIl in space later)
The Certificate of Death containing the above stated pa iculars, 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 fo registration, have recorded it in my Local Record with the above stated Registered
Number, a onis reof EREBY GRANT A .2zolta
to
to
the to hold temporarily an t body.
(U ertaker sr person having charge of corpse) In a ov o of erwi isno tat' ho
Dated./.. G• 19...�jF� (Signed) ,,i
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (suhj et 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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