Corlew, Elois Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rer 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 CERTIFICA E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Regist ed 1. 2
Dist. No. County
„�l�of7� �/ cevz Town /�j� 0
Village! " �' �fe.f / %
Or CI (If city,give street address)
Name of deceased /,/
/. �!/ Single, married, widowed,
Sex Color .or divorced (write the word) Date of D at ,.. . A'S9..f...�
Age Year .... ...... o thsl" D s Birthplace •
Cause of Death. ,,
Certificate was signed by --.2?t M.D.
Address „4 :-.^-'o a, 4 >�. •
Place of Bu,ial (or Removal �/A __-"
(If body is to be te„� ar,l e��,�in apt la i
Cemetery.. .... ' � � ..r �'� Date of Bu ial �- if 19.. ,..1
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated articulars, having been pres ted to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acts the same or r 'stration, have recorded it in my Loca ord wit the bove stated Registered
Number the • th eof BY GRANT A PERMIT
to
ress)
the to hold temporarily an the body.
Wade dr on halt&charge o corpse)
remove,or of wise [e o j)
Dated. .......... 19...�r (Signed) �'�Gi=>i1 . ...K....y . ...
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (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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