Towney, Harold Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregutrar) 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
3
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. Y
//��,�,,�� � � 'Pawn p
Dist. No S 4 0/county �—"�^'>\ Viilage Le `-Sr" "
Or y of,y,give street address)
Name of dece sed • "V-va---re-0--e, -7—er-up-......6-4.--1-,
/',
c „ Single, married, widowed, ��//��
Sex ``�� olo.. or divorced (write the word) ate of D th `r 19 .
Age T Years 'llo�ths /,.3. ....Days irthplace '
Cause of Death /liCe ��"��t
Certificate was signet( by... M.D.
Address
Place of Burial (o .0-nova 4' �/
(IP body is to be te... f i1L4 fil] in sp ce]Star)
Cemetery ,, Date of Burial -- 19
(IP body Is to be .porarily held, fill 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 be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accep ed the same for regis ation, have recorded it in my Local Record with the above stated Registered
Number, a n e a ' `t�F HEREBY GRANT A PERMI���C��� .�`'
to ' a.-ti.--.
( a ddress)
the to hold temporarily nd.. the body.
(Un or person a charge o orpse) move,ory�er dispose state howl)
Dated 19 (Signed).... .. ..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the to (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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