Giles, Blanche Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ice' This Permit can be signed only by the L.oca! 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. o5....
le/ Town G���
Dist. No. Z'...County `Zd c Village..
// (If city,give street
or Ci
Name of deceased -2 .. ..
Se�:TI �, -��,, 44-Single, married, widowed,
.GAColor.1�l4GGf!or. divorced (write the word). la;��k �/' Date o Death.... ..a9. '
Age 4..0- - ars� � �� Months // Days Birthplace �...
Cause of Death�l .. . . C' • /�
Certificate was signe , I. M.D.
Address iA�
fr
Place of Burial (or Removal).... .... . . . .. . . .... . ?jam
(If body is to be temporarily held,fill in space later)
Cemetery 'sate of Burial.... 4..a. 197
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been pr ented me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same fo egistr ion, have recorded it in my Local Record with the above
��stated
�Registered
Numbe��nd on the b.si- h- - . � ERE$Y GRANT A PERMIT � / ����/� .�d�� 4'!'•
to •.- ^ .rer�/,
e ress)
the /...... . to hold temporari nd the body.
( •make/or perso having charge of corpse) remove or o 's....3�� [e to how])
Dated - i 19. .f (Signed) .' Local Registrar
This 'emit /sufficient for the Removal (and Interment or Cremati ) of a o o any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in ich case ransit Permit (VS No. 62) is required.
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