Davis, Henry Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 CERTIFIWE OF
DEATH, LEGIBLY WRITTEN IN DU BLACK INK. Registered No. ,l L f2
.S'ed/ �� T°�u'
Dist. No County /� V-il}age "/(4'(//--<1;114.
,,, ..City (If city,give street address)
Name of deceased tN"'(T�LC�p/�''��ti�
�, Single, married idowed, �'
Sex)1`l � Color or divorced (w to the word) � -�4� Date of Death. " � 197
Age 9,,5. Ye M• ths..., /7 r�ays Birthplace "Fr.' � �-•
Cause of Death (ry /1'�+�`-C as �/�'w-��G.-s � -*-2-L2<�
Certificate was signed by. .... !,',��^�'��_ / . M D
Address y, ��"""' 1• �� ,••
Place of Burial (or ov 1) dy(If body is to be tempo r' Id, in el-do-u71^-
y�
1,( 4411
Cemetery Date f Burial.. /sue 19
(If body is to be temp ar ly held,till in space later)
The Certificate of Death containing the above stated particulars, having been presented o me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted th s: fo regi r on, have recorded it in my Local Record ith the above stated Registered
Number, an r sis GRANT A PERMIT
to . . . ... ... .... .... .
(A ress)
the to hold temporarily and ..the body-
(Un ker or p rson li ving chary�pf�corpse) me ove or otherwise�T,lisp f[state w])
Dated...... . .. . (LS 19 jam.. (Signed) fir/
���� Local Registrar
This Permit is ufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su ect to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
t"►1'e 'dow •*w •y .� �an ovrowo0 n t•,o • 0-,09y w ", e np'{p*a3 ,�•-•� Gp°'jv' d'^^ C7
O n •'3'i n •. O'0 �.`OQ•a z M ,-..,.o ..•.a.... ',' n O n n '>"'n n O a t!,
nxN n ❑ a n n f0 •, F, sw n'. "ww °wa: ., nc. c0 a• b0Y� "0V? m iTi
"�'5 �° rt,gG.'• w ti ?t W� we0'+ �.w.?'cSs ��W co, swnnn .v,`,.._NO w'co p'-I o, n0 * �mi .' 7C< Ca l O Z
2;:ti a a`t'd a n a a, .. n < •., 0.a.;-' n .O n to� trt
x w SNe ,Oa-n P.0 .1 n ..00p •]"0 �'t7 O0.O WN�, n nw ^wt ro I- ,A,.„ ry 0�.,•+,w., P.a aJ •0e 'AZA •%. . pn. ,0,,, d
n0 V1 ym� y y N- m ,N r. �q fD pj a(9 ....in w n n` aj n O O w O a• �p V .•1 ,a ry ..'' 0
w"7.0.,>+ 3."C,,, o ro O ."0 -co O w ,- O co 0' r• �n2,.N., fu
O w n N O P.O ��•.''' O.D .•'t.'•LTJ wkL
FA
; .'<r,'.,•t O.° tuna,-.25t•0a:" nn r'' do *a' ° oO+w ..•, < a ...an woo•rD < w ° o 'C,C 77 to CA
ay •nn w rt n O •+. *O-0 t�7 vfD n 0waw < trnn .nn n2
; Gs:p w a n es a,o-,., ...w o a n ° A' < Cro n 0 `.'a n 5'?;F'.5'T n C.st fl `� ri n 6 y 4 o
ez •mwn � 2. awn w 'dt:.o w '+ ny f9 y tRan �4
p.p'.C I n "'`t '. P..�•n n•O a ,4 0 n w n o w n .r, w CS'n•0'», N .+.`C n P.0 9 X t .d r..,�'p-
.+a '.''� n nwrt n ,0 w'o ..
4 ' 8. ; zw`eo-a1 ' c " zwo o 4.":'—za- M ' °A § 8Rww .,,, ,, ., �, �va •w pii19tnm 3'Z
• O rp o a O_m m ^ "1 .� R .+ �•t .7-�C' �.•3 rii' C N N
M III
N Y¢ L °y',d <•-°1 " r;D,Ny y;reo � mo7 EwR_ a � •E. ae = o •� ai0'� oR �wo „w '...t.7 N0 .
n .0 n a'o•a .rov y ate, P.,...0•O a� O . o� w 0 "'3 0 0 Yo `""i
.0 �TOC " "+OiaawP.00 ,ry. n "na C a yR-now �• -a'O.O < "ft to
0 O ww Nrp Tr- a, .' C ...y �O .+ nw �tr Ow .n, n' •, ❑ y'Ony. wCO•P .0.� p0� a A
.••n¢ 'Y. ^tO .., nron '-0 ...z ., noO ., O al. v, n wn < ., a.w C..O C Z r�0
. ""'�•.w-.'a., na ., ., rm. 0 ..,O nP• Kw0•ny ''� '. . ....
•p ....,:...0 ... Wt
' CA
p G o n w.. '4 0 0 w co o n ro o y _ ril
l"XM M ^a' w x o °n n ° o'o :, +'3•ro n•A°v'5- an '4 PIA' 7+an o cr.P o o w;. ti el Cr pt �'
rt w n n .'l1 A O , '1 tT�o N n7J a0n , a a � f n .. w o- n 2tn
O �n wO ^+ ]'� Oa a•., '� •, w cr..•, w R w HannP,�, n ro n P+ < ,. oC �•.,rt] ro -••a "' n H 00nc. 2n aa, °_ ro a " 0'0 � O �] rt1 �� C Z�1
P.0 ii•,z a 0 c a .4s":p M 0.N0 w CD = 0 w k �.0w ..., R '0 o m.*2 4t,°o o N e'e a^ •°, •Ni I. ! S'.9 y°-a n a
0 O F.,� ° '° ., � 5xoy � ° a �'no 0 ..,� ° <'�prgn a».5a.owo?' nPm "as."1' ��H
b aly•�9 �• =a•C,,, 8 ill
0•0 0, .A 0 *R —0 ,C w R -' n p.. . "yG c y °'sq -" ^ 5'0 pf �y� ►`t.'o
-1� r t".'Vl ,+ a .,>.p rn.'_S-_� .r. _. 0...j ...-M.:r•y.. .._t.�''1 n k..Pi ~- , Q`_...44�... _ ,.1__.p ._.- —
. -,<
.-s+ttCCjj y.�--. .- n - .e4
< a a.+m , w 7 e rs w e w *° < �z o �,., Rtsy - �"
re .-1to�• aaA'°Qo..„ a3aoa-�.,-• •oro o w ❑ O 5 o ti m 5 a a• ro En
O n •0 m ro '0 0 ..•, 0 —n 0 0-w ••., w O .0, VI w 2."nI
44.0 . O,w O < �.w.•ro C a Z O n ti'Oa rt n P.� ,° U' a,.w-.n n m Z A3 4 R w w O w w.� N .iri tl Nra 9'=row
..�. ],� 5"•-• 5-y O' ie O 5.•, n `O'n a' Fb'c7 y a., rae w'S a w O R ,,,.,/v
rt`i1.1 Fina.o a • P,wo ., », 0.r. renw �+' 'c75-•x0 ..,ao, ocrA ., awo ar" r ;; /"t70 0 ] '- �, :a t�r.y,$ce '' gw _nro �•ca r, ow ° .', n ov ro w °, nn n. rt �i�]^, ..n "�.O o'.w...wn W.'*...�-t .J,� ° n ('' n •, C w n n'tl ^f „'x Q.CD �.a�n .~-..° f0 P. N .URN Co �+•�rrl
,d 0 2tr• rn.O'?�0 wt .--0 N ro A... "",o, 0"..n n a p,•P' 0 a4n < 0�o n y. . 0+A, 'Oi M 0 O-` p �. p, p g .�'�" XJ
OK7n n i+.pip ...�,�' ..,, K�.'�, n wwH' b �' w O P,....,'.- •*NOro ^+ ..rC M N n a 0. Nn CFzO
.'�• <m � °�'.• nOraoO'r, Cwa,?a ~ r*O � n�m� n �xa �,�na� n ° aaaro ,, , _� Oa,.. •■ ..0a•w'
1 ti7$ O .,,w .9{ 0•X,6• g, 5'ul' ."+r, 0 -a a ro „ ]..n ^ ,w .i N 0 R.FOR .°t.0 a, r to n H a .R pay
O n .n, •, rL x p'A, M N A> T ~ w ... ,Y n• ^+ a.n 0 a p 0 CI , C~�.';":d K•C7 0 [C �. '"i `•,y
»a O m •e ., � 2 n o r°Qn b "'- Mao __y° o O'b°Q.0, r, E.2 ; n 9 y a@`a w K .0- ) I .7 n �;'n mac•,•,r
rt w.n n n,a 0.. ry O O_ w 0 O a°' „•, •,w+n 5.P•,',.0, w'O 'n < a...O.s ., y.�� "0 A a...* p-on �2
0 E !' a o w O n ..,'-, n 0- r.O .,ti O ,.,,a ro a ro a4 in • "1 n,w U)
is n 0 y + 0 a 7''+ r, N'S n w,b ..O'•t y 0 a w w n w o-
w .b Rew �'.b ro �•., w � O'�.,O o-co ,..•wi yP .^.Q''o ,r�"•'-owror•k •"°Cn' M0 •�^'e�'+ONY � A
... ,.: c w �..'-'reo•owoyfD0a.h. •, n 'n0Oti �'i y'a000 � co ,, agar" xm o
4 -ter c.r'°o nw'C �' ~ O aw ro r n 5''e�•GO n w n*=y`P:2 R m�b 0 w•0 ..,c 0.e ,-IT�G '��'
n pn •, wOnn P .nYOO .°nn. ,°..- '< ❑0'4 re Da EY 00.tx..�rt.A, � wPP O0. I..0RXI
o^a :V4, .4-n we ,_ 0 w n'Oro w `' �`. .y a a 0 "CI .n •w ° ?:` a"' P �C�. C)
`.. rt nCT,- a Gr. ., Oa 5�k 05.py• ✓'0' ., ., OO •HNo Oa'., ^`G Cp. i,,.,
� M4 E ° CK 0•aw 0. O k g .n (,+" 2..0 ". ' S v, $ a ~ G 6' -$ 0*^0 3 n'o �D 2� m
n0 a w wo -, `�•cr,. '0 •, ^+ v, 5 s n'o �. orn G
p,�e 5w ° � .a�a �ao �nNwaaoM•a �or2.wZN „ °2- gorgoo'rnc.o w, �:; III
t=7... 0 CD OC . re CM .A 0 w '4 n re ...: —.n 0 =cm '< m O P,a.w 4 0 0"- ., 0 P•0 0 v w 0