Wilbur, Eva Form IS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
g2r 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.
�j� T-ewrr
Dist. Noteo, Count)/"7 ,7. a Vittage... ( .city,
End _
Name of deceased / ' ity
(If city. dive street address)
Single, married, wido ed, W
Sex X Color.,,. / c,r divorced (write tie worepy7 .Date of Deat .. .. . .. 19.)r,5
Age e Years • onths Da • Birthplac .�� � / /
Cause of Death ...
Certificate was signed by 722z,,.. .AP" ..9.,L, . .... M.D.
Address
Place of Burial (or Removal) i✓�Y� .... ,...'r,,r /f'
(If body is to be to ,y�arily held, 1ii fnppace later) v
Cemetery „�fr�2G,....(,l,.e�../..i.�i Date of Burial .G2Zf. 7 19./.,`
(If body is to be mporarilp held. bli in Jeer)
The Certificate of Death containing the above stated particulars, having been pr nted 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
Number, and on the ba 's t f I R Y GRANT A PERMIT
to.../.�.'. °
ame) ���; (Addre
Dated G 19. to hold temporarily and .�,��. the body.
gest.P414167
the sa
nd aker or person haying charge of corgi) (Inter,re..ve, .r oth rwise disp [state how])
(Signed) ,..
.S.eearRe s ar
T Permit is sufficient for the Removal (and Interment or Cremation) of a .od any part of the State (subject to local
cemetery or other regulations).unless removal is by common carrier.in which case a T ansit Permit (VS No. 62) is required.
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