Smith, Carrie Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 CERTIFIC TE.DF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Re • tered No..__.
TO Dist. NoY4� 7/ u� County.... age -4
or City f city,give street address)
Name of deceased
,J SIt,gt „;�, widowed, �"^'`*�Q
Sex r Colot/6 orsluFep �
eed (write the word) Date oy?slatil.... .......... 19es
Age G 9 Years 4 Months / L Day , • Birthplace ,. `7'",r
Cause of Death
Certificate was signed by . ... '?['� M.D.
Address
Place of Burial (or oval) _71,
I
(If body is to be tempgtl�held,811 in spa later)
Cemetery U Date of Burial 19 �f
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to , after careful exami-
nation, the sa appearing to be C 'IPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accep the same f r re • r ' n, ve recorded it in my Local ec with the ve ted Registered
Number, an on the basi f GRANT A PERMIT
to
d s)
the to hold temporarily an the body.
•fltaker or perso aving charge of corpse) ( ove,or oche di of[eta w
... . re
Dated .. ... 19.YI (Signed).
Local Registrar
This Permit s sufficient for the Removal (and Interment or Cremation) of a body to any part of the State subject to local
cemetery or other reenlatinnal_ unless remnn,el is A.,...,m....... ..........
1^Ho 5 0w ~•Pg•stenEcnoM oEroPoO n ra " °~.onNw " < ng�+a5. »•^'y t:1;HUf •,.�
o VI " " " p0 ° n .", to ° = fo 0 G°-a, t, �-�.� 00 ` — -O � �s0 �'•0o - 0 '�� a A v M
n x" n ° c n n n " w ".?;w x. "p; , n pv '4:^ � n N Oo 6 01>h7 ro". m ►1
2.. n._' `to <'t7awna, ,om �''W., a ° nto -• ,.,crq rw" � r. r ..,'�" yavti'� yn ° «"tNco, 't 7C� "Ga �0 Z
70 . w o " a.o a.w " n .6a-'„o „ cr5.n ,,,r..4
o tvn ° to v, wa G . n ml ° n Vo t+9 ro m o cE
cp ,�..m y ',='<,.5. n0 11m ..0 Op" ° tob 07 O p»,V n c, w' CD.••, C `"p4 � .n no .^,U" a.ro..44 " �zti MI av •" ^
PO
p w a N .°�,� "„w ',,°' e W ~ y 0 Ya'.�,�. n•
."��•0 w.Q..°h<'n "°.3 ° f~o N +0-. CA• "1.' V 0 \/ a�
VI
ti H o ti o a.° n o a N w I. w g *w n tv" w 0 2 .. ^•a.° . n o o 0" CrJ C..a
,.�"..j tc .n .�7' n to 9 O 3 O,N r�i N O tc < 0 O C/1
m 0 CZ O xa." 2 atna ' wn �} 0 tov0 ... *5•odavnx.......,-. y' w < ° " n "' nA k QH00' �ylT1'1 �,..yy �' n M ". w O O .p ti cY *° w 6, n w•n , r...w..a•O n r, •1 n'�
0ov' " z"e ° a � away " < ° °, H� � ac w � na w �T' abGN'��" ay � °9.nL��m t`riLT1
1r m n o°Q P•0 0 a. A Z-• •x a- § o n w __• n n n .�! 1y
o f ° n Q,ro w n �••`�'� N a n N ^n'1 w ~ N n o .�.. "I •x G y•.+ ,OA m R ~ t �r" yy m a Cfq `." C .n, y a'N G O" n Rx, a E w -, .4.,°.� a•< 0 ,N..n w ° 0t 0 ,ry.Ar 0.,�:., 'n A " .. z•`7,4 I
to 4: ,-.n °'c° ,-.n o " Nam. a..ct1..
c w w �� " ^-w� ° �3 0 ""
pi
4 CA 0 C " "p4 C a.w P.o ° ° c9 i. p IIi!
,,," •w t • o 2 •' Oo✓ 0`0 `•4 " " O -.." a-O 0 a° " nS' 5-w x•N+c.•-•- ,". a a...
5-• XYi 1'1 ° CAI X' ttsm 0 " n cr. 'r' ..to .�`" .. n w .-.D, n .w+n 7, n 0".w+, •p ^ar •"" a `'J
° 'ro na°, ,.., 0 ° '^°" " �.0 O" .n, e+ ° nio'(Dm .y a." ° w w0cr°"y N " w ",r•C+1< •, ro Vi
a ",y co w to o o �b o g n w•o o o•o Cr • • 1Zrrr7i:! C
! iIii !
a A - ' i
• ie= �C' 3 Inas
• -00bwayw" �' O'°a-- nr"�. n'•< S a ; ' �A2
a• N ! •° ° a G. »w n .w, L , , <• n O N N < p C `C 0 ?,�i" " to.. '� Z
m H .- 43.-w... •.YN C3..M. P, ° x,"..„. •o fn .7. w «'3 O 0 •-w .°r°p a•Lt, T"O "
.: CA wxnN•p " no �� <"'° ° " o n Nw »�° -oRsn F &g. " z n xC
,d0 a Fal- ° B ?;n •oa ° n, " �'" ' a. 0 Nw•Nw` ° c 'nc �" R.> 2 '�7:••la r"n_ • '‘ i
'Ti.-i �,i. •' ° B.^ :." * A+w o m ° n w-" �� a w ° c o n o " " ."" w o a.ayC.e" i g r ° I. 3 8� M)1... /
""r1x5' a , a.:'agN ' ,'tn" 3w a5nv9 00Co 0 0° a" .., " tonn _ w °• m (0 If•o '" .. s P Z
R `�.>� ^'rt ti a.N ,w-,�• ° °«i M° O n n G O DV
r"i, in <`0 " ?2, n n�_•`•`G 8 " c 0. A rt'le O ,_ o .,,3
cp `Z x O ^n .�i `C O O " C O O n 0... N O "'t a,. ,H '+ `d fC p ❑
,� Ul n c•�.° ,w,c " n txn ... ° •Ry w•b•v a.p.,.•N rD ° G,,d < x'c7 " " G rn O" 'd rTl o "A 3 ` CI rz
o 1•71'77 n 0 ...p1 ..0 x e 0 Z." " to o N m' >'• N n o n to� .+'n n .^..tom,, -•ar co O O °' •"A m a co �y ry
A. <,P� n "• a n E''..^v,'w N n M n ,b n ro•a b to 0 w t Win•9 w ^ .,•n " M p:-, w n'"1 ,Oq. f., . ,�'N G/1
yC17$ = � n o to xn ^p? " ° ° ro ,°, .n, " 0•° a-n . �, o � a o 0 o 0—E.0.: +0 " "e P 040
!, " CD' �.ax, .w" «as•w�"N' ,n.� rn. y O °. 2 et,
pc.,
x" " ,.. " , S :O'pR ti'0 in 1" to H yp, .jt ., -_ M 1'1 Z
"omen " " " cry" n ;� " N o ...�oa .r *n 00 ° "= nc yn �'x� n0 y wC m
m^' O y C " w n n pa w"" .a O ° w w �y p4 A, tnj r) it r) v r•<^, n G°.P? .-''"" tin G 0"" " 2 s.
,,.,,° 1-',.., ,n r - n.°° O:n 0='7, ° ,9'�-• N ,°..,° �.in',1 5.C'� N• ;? " O F .x :t .a'4 O^°'(7 0.—(p 0-0
o $ t."� eB ' Non " w ° " ro nx .'o «, " " 0 °'to < c, ar �Z wpa n Cl) -1, pi '•' �x
F. 0. oe ,w_,'0 '.' a° 0a-•niNy °.IV 0 °'�'0xn •-*"- o Ry n " . N x • xw " ?• A
•o+`M S. w ,A'' ^N Q•,0 w o N :: 0-7,:t) ,w, 0't,0n n.y 0 0 0. N ° G •t o 0••o :•N f<i� ,-•. •a..tn"n a•C" «Z 0 T' "• o
.. o �y_ o ° = asps ° °' gi. • P:ow-".< a.oa " c ' 0 •-• o G ��
n " zA a � .ti= x wn0y .0E' o� ao,< ,n" n * -awl n -t r H
o „ O w Jnra, . .;0'S °, tnN oat-„yNnC"., •• c''P 0 =w x�0 7 /7i
......3 72. r:net, �.° n ?,.r, 'n w � ° g ,,•a c "d ..,o y•- - w.° o C K �,'�
o ,�„q o c a•N � O� n nx " no '"°• ° Ncw "' nG " w'Z�•"`° n h7'Oz Nrrl
nOa" �, c�� ° w0 -niS.Q.+ •o «ne -'"i " w� � < aN tit° - na ° - , - ccoo nd� / co
0 23 5-..72.. •n w _•at�;°.en 0 " w n c w" ..... ,-.C•� " a'0 n!n c " �•�.< ^" C+1
;1'(T1.°„ 0'too ::0°Q 1 too 0Q m ° m .na•`<°•, re 'r-'. •=� 00 5-aq `e-°i E'G'?' o n.5.w w 5•° ni 8 0.'"' t2 8 v ,, a. .0 it