Gardner, Daniel 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 CERTIFFICA. VeF
DEATH, LEGIBLY WRITTENIN DUI ABLE BLACK INK. • R ister d No.....(,r
Dist. NQS4 ( County- laliffaly „,./10-44.-ce ......
6) • 7,, Y or City (If city, ' , street address)
Name of deceased City..
nglc, married,iwidowed, �/
Sex.... ..Color. 1' -orcec. (turi he word) ate of D' th... ........ 16 19....-�
Age Y ears...
g- .�.� T ��.,, �n ,� .. .. Days � Birthplace ... /
Cause of Death
Certificate was signed 1, - ... ....cr. .. . • NI D.
Address
Place of Burial (or Re ova
(If body is to be tempo r'1 el ,1 ./A ������cc S:�terr
4
ger
Cemetery ! Date of Burial �� 191.4T
(If body is to be temporarily held, till in space later)
'The Certificate of Death containing the above stated particulars, having been presented me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW,
I have ed the s e for gi ration, have recorded it in my Local Record with the above stated Registered
Number, on th b is er HEREBY GRANT A PERMIT / -
to - (�
(Na cress)
the to hold temporarily and,e' e the b
(L'nd k or person ing chargd gfecOrpse) ,-f IIe r other ' edy5p6e o e how])
Dated 19.. .s (Signed)...
/Z--' Local Registrar
This Permit sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject o Iocal
cemetery or othe regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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