Cheyne, George 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,
✓illage, 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.
e
)ist. No ,�rb6 I County 7y4 _ Town Village .-;14-611 7 ¢'""4--4"L 1 ,(-�//�l�
or City (If city,give street address)
came of deceased £ 6" L'l 7 4.(.._
,,/
Single, married, widowed, • f g ue.
;ex /1 Color or divorced (write the word) h� Date of �� '2 19.T/s
k.ge 7/ -Yews 0 Mont s.... iz Da Birthplace... d-- vim- ' ., h
;ause of Death Pt7.
certificate was sign b Cka M.D.
Address ..�� r
'lace of Burial (or Remo al) 0 -� 4 �f.
If body Ss to be �porarily helyY 81]Sn epafle later)- y
If body
is ? -ff+�'�� (�� ^^'" / Date of Burial �°'? ii. 19 �sl—
If body is to be temporarily held,fill in space later)
['he Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
iation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
have accepted the same for registration, have recorded it in my Local Record nth th above stated Registered
lumber an on Abe be is reofoi,te. /ey
��� E EBY GRANT A PERMITT S , e / c�� ,
...me) Ci(dress)
he to hold temporarily
.�-wt Cat the body.
(Un rt er or,�erson having char ofsorpse) /42a1
othea dispose of[state howl)
)ated C. "Z�", � (Signed9' Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of th State (subject to local
emetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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