La Point, Frank Form %S.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
r' This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tow]
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE0
DEATH, LEGIBLY WRITTEN IN DU BLACK INK. egistered No. 3 ,[
o ko/. - , mo o
Dist. N County.. 44alie
.. . .. . .... .... . .. . .
// or C (If city,give street address)
Name of deceased •
�e�J 'Single ,.� s,
Sex Colorl'/.4"..'.1.. ...or vorced (write the ord)�� Date of _ 19. .
Age 4 Years T Months f .Days` i :irth ice. .. it.�%Civ ">1#7
Cause of Death A
Certificate was signed by ,,�� M.E
Address L..:....... -)4..
Place of Burial (or Rio .. . I
(It body is to be temporaril :5I., fil a to
Cemetery Date of Burial /- ,' Llp
10.
(It body is to be tempo .rily he d. fill In s ce later)
The Certificate of Death contai ing the abo ,e stated particulars, having been presented to me, after careful exami
nation, the same ppearing to he COI• E, CIRRECT. AND SATISFACTORY AS REQUIRED BY LAWS
I have accepted e same for r 's do v 4 J1 orded it in my Local R cord 'th the ab to Registered
,
Number, and the basis h , ., • • NT A PERMIT
00,
to ..... ..
( s )
the to hold temporarily <n body
(Underta r r pe•sou vi .b vr
_tiara f orpse) ove or other ' dish ![state bo
Dated „dal
- ��. 19.. . (Signed')
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sub ect to loca
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