Brownell, Carmelius Form x S.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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.
c r, , Town
Dist. No?J G �7 County �/ Village
or ity (If city, give stree ddress)
_ •
Name of deceased....l./ - --C��� K .
Single, married, w' owed,
Sex Color ID or divorced (write the word) 6 Date (4 eath:.. i % ,,...19..c.f)
Age.... f.../ Years 7 Months ...
� Days Birthplace .. ,
Cause of Death .61,--1..Z. ... .. .. ..............
Certificate was sign .n. (ti- 0 6-4. ! / M.D.
Address
Place of B uri or Removal). . L,e.... �--�J Qc c
-lel
(If body is to b .orarily held l in sp t later)
Cemetery ��P (/ `�J 4'�� t.�� Date of Burial a2.. 19.. �1
{If bodyyis to be temporarily held. till in apace later) �
The Certificate of Death containing the above stated particulars, having been presented t me, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same for registration, have recorded it in my Lo Record with the above stated Registered
Numbg y and n the bas�isr�the I H EBY GRANT A PERMIT 4
a_e,67• I y
to.... ��t .
(Nam ddreae)
the to hold tenlporar- and the body.
LT dertaker or person having charge of corpse) v , rot rw se dispose of[state how])
Dated.. 2..`.' 19 ' ,I 1— (Signed) '�
Local Registrar
. T is Per t is sufficient for the Removal (and Interment or Cre ion).o a b to any part of the State (subject to local
..o..,..t>.o .,. .,th... .ei nl,.tinn,l_ unless removal is by common carrier. in which ase ransit Permit (VS No. 62) is required.
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