Saville, Tracy Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t''A This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Towi
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIfjc#TE-0
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No........ '5
Town
.�� - .
Dist. No. ..6. 1.Count °
y... ... ... .. Villa e .. ��c/
(If e' y,give street address)
ame of deceased.. .. ..... .. .. .. ... ....ot):
��/ S' , married, widowed,
. ...
Sex .e.. Color... or ivorced (write the word) . .. . ........ . Date of Deat 19
Age.....S Y rs 3 _ Months..... ..., .. .. ay Birthplace H .. ✓
Cause of Death... . .. . .. .. . .. . . . ,
Certificate was sig ... .. . . .. yj I
Address... . . . .. j�.1
Place of Burial (or Removal).. . . .. .. . .. GC
(If body is to be tem a rll .elQ, a pace la r)
Cemetery.,r.-.. "%Si.. Date of Burial v.,,te a'. - /2 19qei
(If body is to be temporari y hel ,1i l in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY I.A\V
I have accepted the same for registration, have recorded it in my Local Record with th, : • .ve stated Registerec
Numb and on the is therMITN(ZANT A PERMIT 4-itto... .ems. . t
resa)
the to hold temliorarily n .. . . . i 0.' hod
(L' er erson g charge case) me v ,o othe 'se dis•.ose feAstate h.f; -
Dated y' -. .�✓ 19 (Signed) -� %/l"
,/ Local Registrar
This Permit is sufficient for the Removal (and Interment or Cre.nation) of a body to any part of the State (su.j ct to loco
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