Dean, William it • - - _
Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
" tf OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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. /; '
Dist. NoS -‘49' County h -4k Town- Village...//a-s •
'// Or Ctty (If y,give street address)
Name of deceased 1 �. � �
/��r L Q, (i� Single, married, widowed, •
Sex.. .. -S Color or divorced (write the word) G Date of`D/ath.. /6 19. ..,.
Age 7l Yea t7 Months /0 ...Days Birthplace..11�' . ... ..
•
Cause of Death J`C�� - e�" �, jte.„.„
�p
Certificate was signed by r�,�. M.D.
Address 'ice ,'.. �f F.:.r.--0„....7
-
Place of Bu;ial (or R al,�
(If body is to be tempora : Id,MI'n sp ter) . !/
Cemetery o be �t e later)
Date of Burial G� � ,�f 9.T
(If body is to be temporarily held, fill in space l
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 acc ted the same for regist tion, have recorded it in my Local Re
rd with the above stated Registered
Number, don the ba 6r-;�� Y GRANT A PERM L!% .vt. 0(4.r
to e s) ZC-oc.p
the to hold temporarily and the body.
(LTn aker or p n having charge o corpse) ter, remove, ttherwi dispose of to how])
Dated. . /? 19-. f ' (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the S 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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