Prentice, Marie Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Car 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. egiatered No.
,// ,,{{•��// /` T it age..wn , F-�'
Dist. Nd .,i��.J..LCounty ' (., �� n o
, (If city,give str address)
Name of deceased --(.4- ,, .... . �i} --441,i
Single, married, widowed, 72 '
Sex...9 Color..i(.(e) or divorced (writ the word)../../..1...Lz'Y�r . . r
Date o DeathC7.:.... 19..
Age Years at 1\4 nths....,., er ,►. Day Birt Iace .1� r....+5G.t��t,et a..( ....... r��, (
Cause of Death ,'� e : ` lam
Certificate was signed by... . .. M D
... . ... .. . .
Address 0:"4:
c�Place of Burial (or Removal) -- rai
(If body is to be temporarily held, 811�ttt 9uace t )Cemetery , T ^� A
G .... . ....Date of Burial U:7�"...� .F� 19..
(If body is to be temporarily held, 811 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 he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ccepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numb , and on a basy�th f I HEREBY GRANT A PERMIV�- 9,
'�
Lh n.c - .u4.to ( dress)
to hold temporarily arid the body.
(L;s a ker or per o having chars of rpse)g (Inter mov//f�or herwise dis ose of(state howl)
Dated .Q"7� i 19..q (Signed)... ... V/
I y Local Registrar
This Permit is sufficient for the Removal (and Interment or Crem ion) a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in hic case a Transit Permit (VS No. 62) is required.
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