O'Malley, William Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
IN' 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. 171/
Dist. No ,7, .6.County Village '
`_ .. (If city,give street ress)
Name of deceased r7,// 0 )o���
Single, married, widowed, - ��,.
Sex.��-4-Color�r divorced (write the word).!/ Date of th � 4, .: Z. 19 CI a—
Age i Year . r Mon s..... ...3 Days Birthplace....
't-7.A
Cause of Death
Certificate was signed by M.D.
Address � ^ � � GL,--A, 1Place of Burial (or Removal) 71 • h
l•
(If body is to)s,iem a 11 1 ld,fill in space l r)
Cemetery. • Date of Burial . /0 19 ''' '
(If body is to be tempor ily held,fill in space later)
The Certificate of Death containing the above st ted 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
Numb r and on the b ',reef I HEREBY GRANT A PERMIT
4 t7tieeel' 8,-
Name t��t�—�.-- (Address)
the to hold temporaril and the body.
( maker or pe on having charge of corpse) (Inter,re,(T- Jr A'erwise dispose of[state how])
Dated �' 7, 19 tt14-- (Signed) kit .v
` •, al Registrar
This Permit is sufficient for the Removal (and Interment or Crematio 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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