Rivers, Leo Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 / 8
Dist. NoS /
1 County figer-1"1w'-% Vi,lla e, r
7, Xv;,.(.....gooraCity (If city,give street add ss)
Name of deceased !o(rL,
MSingle, married, widowed, • •
Se ... olor� or divorced (write the word).. . .Date of D h.... .... /6 19��
Age i.-d Years.... —S. NArith� �� Da •s • firthplace...�_ -'' •
Cause of Death Q" -e ft,c., - !/ _c_il
Certificate was signed '�� .,.ram ' M.D.
Address
Y'lace of Bui ial (or R oval)
(If body is to be temporar' , fil p t
Cemetery .... ....... Date of Burial 19
(If body is to be temporarily eld,fill ins ce 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 acce the same for re ' tration, ye recorded it in my L 1 ecord with the above stated Registered
Number, a on the ba3irher I HE ANT A PERM ��&
to
L./ (N "2 -- ss)
the to hold tem oraril an .the body.
(Uad er or De on vi charge o c rpse) (I move,or other a di • a of[state j)
Dated.. ` tf' i 19 (Signed)..... . . .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( ubject 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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