Harris, Byron Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
• OFFICIAL BURIAL (OR REMOVAL) PERMIT
L5 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.
,[ Town do
Dist. N .County ` W Jdillage..
g Name of deceased .. .
_ (If city, give street a( .Ss)
Si e, married, widowed, ''''//
Sex y Color. or divorced (write the word) �/ f�!4 .Date of I)i tl r 1,, �.
Age mil` / p.+..1 e. s C� �1ont.i ...... .. Birthplace... J�IaX�►' -.
�Pl ' Days
Cau c� of Death
� ...
T:ertirtcate was signed by ' if... `vi.D.
Address 9- . .. .e-'
1"•a,: of Burial (or Removal) .----t f�L�- U/:14-4)....
(If body is to be to aarils eld, ' space if m"
Cemetery ( / Date of Burial.,.. /..( 19..? J
(If holy;Is to he temporarily held. till in space later)
The Certificate of Death containing the above stated particulars, having been pre.ented to le, after careful exami-
nation, the same appearing to be 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 staled Registered
Nun�F t�, and o basis eo qTer--1-414-1
GRANT A PERMI 011.114AWL.
!!� Name)'61,.- ddress)q�, „
ti,t: to hold temporarily and the body.
rwturf. r .,r person ng charge of cojyse) (I r e,or oth 1•ie dispose of [state how])
Local Registrar
its Per ' is sufficient for the Removal (and Interment crna l of a body to any part of the State (subject to local
cemetery or er regulations), unless removal is by common ca ier, in w ich case a Transit Permit (VS No. 62) is required. ,
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