O'Malley, Louis orm VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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............_...._.-.__...-....
v Z Count ! Town
Dist. No.. y f Village
or City 7/27_,..
city,give street address)
N ime of decease .... .. .. ... a
• Single, married, widowed, r �/
3.
Sex.....�7,. Color.. or divorced (write the w9rd). ,.. 44a.1.!1r1A.4. 1.....Date of Dea.th.. 191..
Age Ye s.... ...... on s .. ....Days Birthpla e.
Cause of Death.... ' _ ... .. C
Certificate was signed by ,c.... . M.D.
Address ,
Place of Burial (or Removal)/7 .. JA.A......
(If body Is to be temp held,fill to space,late )
Cemetery .�� tw. Date of Burial 19.1/3
(If body is to be temporarily held,Lill in spa�yy la ) '
The Certificate of Death containi{I'g the above stated particulars, having been press ted to me, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Nu b r, and o th b reof I HERESY GRANT A PER T r
to .................. ... . .. .... �/ ` a- --k.i
a e)L �4 I� d ss)
the... to hold tempo arily and the body.
(L�nd take or pert having charge•gfJrpse) �J (Inter, re r otherwis isnose of[state how])
Dated. Ll! 19..5 (Signed). �� cKf�llh.... . 'V
Local Registrar
This Per is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject 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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