Cronkhite, George Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
13r 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.
reei aJ laer.�.1 Town 4"
v- age
Dist. N ... �1...y:.County... . .. . ...
1 � (If city,giv reet address) '
Name of deceased ... .. 14,.. . . .. . . . ...
Single, married, widowed,
Sex . t...ColoiW.J.1,. ..or divorced (write the word). Date of Death.. -..2.3 19..' .4
Age $., Years.... ............ Months 1 y Days Birthplace
Cause of Death . .... .... .. ..
Certificate was signed by .... M.D.
Address �--�}
Place of Burial (or Removal) (r'rAm.d v
(If body is to be temporarily held H11 in ep e later) . ,,,�
Cemetery.. .... Date of Burial ....°. 19..
4,5
(If body is to be temporarily held,fill in spa 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 LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
N er, and on the sis er f I HE .,„By. AR NT ERMI
(Name) ( dress
the.... to hold temporarily and r the body.
ndertaker or person having charge of corpse) Inter,re ov ,or otherwise dispose of[state how))
Dated.. Pt2 ...,' 19.44L. (Signed) �G/f
Local Registrar 1
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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