Fisher, Albert Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ta- 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. No.e 4 s`7County4 Town
Viii�ge
Name of deceased
6 t . (If city,give street address)
Single, married, widowed, `L
Sex "Color .or divorced (write the word) w Date of eath / 7/ 19..T.r.
Age I..►- Years rMonths )-'/., oys Birthplace.. , ,•
Cause of Death t" �'
... . .... ...
Certificate was signed by I 'may .. M.L:
Address ' j / ?� ,
Place of Burial (or Removal) O Zbr
(If body is to be temporarily held,fill in space later)
Cemetery Date of Burial........ . .... f 7 19. '.I(If body is to be temporarily 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 accepted the same for registration, have recore-d it in my Local cord with the above stated Registered
Num r, and on th athereo G ANT A PERTto. / A D ��
. .. . ..... ..
(Name) ss)
the LZ> to hold temporaril a .. the body.
( dertaker r person hiljiSparge of corpse) nter m o r se di no of[state howl)
Dated / 19.4' (Signe `
Local Registrar
This Permit is sufficient for the Removal (and Intermen a of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common ea r,in w ch case a Transit Permit (VS No. 62) is required.
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