Peppin, Marion Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. Regi ered No
Town —
Dist. No...±.S County... Village.......... ..
y or City (If ci giv ddress)
Name of deceased /�GQiL�e'rr/
Single, mar widowed, 26
Sex i-e),. .Color or divo ced (writs e word) a e of lath 19..;YAge S Ye 0 hs Days i hplace V/ Oz�t fCause of Death flfU.� r
Certificate was signed by : r M.D.
Address '
,�
rl
Place of Buri (or Removal) ®61.4Yt
(If body is to belt mporar y held,fill in p e later)
Cemetery 1 ate of Burial • 2.8 19 Y'{
(If body to to emporarily held,till in space later) 1
The Certificate of Death containin e ab e st ed particulars. having been presented to me, after careful exami-
nation, the same appearing to b P T , CORRECT, AND SATISFACTORY AS REQUIRED B4-,a-e-tY LAW.
I have accepted the same for re str o , have recorded it in my Local Record with the above stated Registered
.-,
to
Numb nd on t�hg basis e " f I' REBY GRANT A PERMIT Dr 4
rei%
m (Add ss)
the .... . . .... .... . .. .. to hold temporarilyy and the
the b y.
(Un ertak or person having charge,gf ccArpse) q .. I er,re ove, other e disc se state how])
Dated.... . . • 2..7 19 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod '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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