Traver, Arthur Form 1 S.61. A., = J NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
for 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 CERTIXICVE Of
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. �IR�egistered No.... J/7
/� f� Town 3 �4 ..15!!I..: ,,e4, f is
Dist. Nei ‘67 County �^•��� r��.:4.� Village.
(If city, clue street address)
Clty ��
Nalne of deceased... G
02 ik Q . /' Single, married, widowed,
+ex,/./.�. ..... ..Color. �C/• or divorced (write theword).. .. .. . . Date of Death - . • .. 0 19.77,
Age..... ' ars /, Mo hs... l Y D in ace •..
Cause of Death,... .. . . . ... . ..'/y
Certificate was si y �.
' , C�� \CD
Address.
Place of Burial (or Removal).... .....,
(If body Is to be �porarily held,fill In space later)
Cemetery U,...-,, .�..te,� Date o Burial :,-s 3 19 rf
(If body is to be temporarily held,fill 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 LAW,
I have accepted the same for registration, have recorded it in my Local Record with the ab yestated Registered
Numbe a on thfr basi the f.I HERFY_GRANT A PERMIT 1. T..: ':! .t
he body
(Und r or on having charge f Qpse) ,remove,or o , "ow of[a o I)
Dated VC: • ( i 19.�...5. (Signed)..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ubject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) s required.
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