Shawn, Rachael Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
VW' 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.
5-6 S., Town
Dist. No 7:ounty 44 Village
or City (If city, give street address)
Name of deceased rae-C-ges...G.,
��,, jj ingle, married, widowed,
Sex71"40. ('olor GL/�"'Y'r divorced (write the word)GG —�""-�"7 Date of Death �� 19 y
Age F•Q Years../. Months ?^y . Days Bi hplace /1
Cause of Death . . ... . rweyt.74
Certificate was signed bye./. _ • M.D..
Address...7•,- ., `-4 j' —�.�7 - r`
Place of Burial (or Removal) ,.�t� , --4�--� �r l= ...
(If body is to be temporarily held, fill in space later)
Cemetery-. Date of Burial.G C,e`-'1 3 19g..S.
y (If body is to be temporarily held.fill in apace later)
The Certificate of Death containing the above stated particulars, having been presented to 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 Local Record with the above stated Registered
Numb.
umb rJ�G don th asis t f REBY GRANT A PERMIT tig .. ge 2
rasa)
the to hold temporaril and.... . the body.
(U ertaker or persoon} ng cbarge of epapse) er, o ,or otherwise dispose of[state how])
Dated... '' 19.1.le (Signed)... . ,
Local Registrar
This Permit is sufficient for the Removal (and Interment or rem on of ody to any part of the State (subject to local
cemetery or other regulations).unless removal is by common carrier. in which se a Transit Permit (VS No. 62) is required. '
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