Deuel, Charity Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re 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. _..._._
L ty. Town
Dist. No ...` ,.. .. ....i1
. .. � ....Coun .< ' .` � ... i Village '7
���.. 400 f / , -C,ity .,-` (If ity,give street address)
Name of deceased.. .'........' Y
Single, marri f widowed, _ y�
Sex...... ..- ....Color.. . .......... ,. divorced (wri th word . . ... .. .. . ...Date o th . .. ..199....4
Age Years... .Months s p
Birth lac d!`
Cause of Death
Certificate was sig d _ .,t. .. ... __ M.D.r
Address '
.
Place of Burial or Removal ............�Q ... . ' y
(If body is to be orarily held, apace later) /
Cemetery.... fxr... . .sr4c;e"- Date of Buria . .. ' ! 19.54.�f
(If body Is to be temporarily held, 1 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 accepted the same or registration, have recorded it in my Lo Record 'th the above Registered
Nu d di ba ' eof SREBY GRANT A PERMI
(Name) (Address)
the to hold tempor rily a d ... the body.
ggn taker or pe having charge of comae) (Inter, remove,o se disno o tate how))
Dated..J.. 19 ...3 (Signed) (Inter,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b to any part of the Sta (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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