Romaine, Joseph Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tw 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 alter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABL LACK INK. Registered No. ( .8,7._.......
Dist. i\b-
-6 d/ County T.ciuctlV llage /2":"•45571
ity (If et give street address)
Name of deceased
I Single, arried, widowed,
Se .Co divorced (write the word) ��Date of Deatha G 19 �-
Age .-Fears Months.. ....� Days Birthplace... .
Cause of Death.... T
Certificate was sign bar Z., C M.D.
Address...,.rr� •
Place of Buriat (n .e love] dam^ .
(If body is to be temp el c ter)
Cemetery Date of B ial 44 02 1 .
(If body is to be temporarily held, ' n space later)
The Certificate of Death c ntaining the above stated particulars, having been presented to me, after careful exami-
nation, th - me appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have . ted the s: e for r. tration, have recorded it in my Local Record with the above stated Registered
Numb- ' � • . <si: I HEREBY GRANT A PERMIT /� /�
to ' y , ....e(Na..
+ - .i��rJ �CG.7rf'!- ' l �i � ,
(Na..• ( ss)
the ! to hold temporarily and. �.. e body.
(. •rt ke • pers having charge o corpse) `'///(jn ove,or other disc of[state h )
Date. .. .. (x 7 19.., (Signed) ffiill��// f l
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (a ject to to
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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