Mc Donald, Arthur Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
; This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Towi
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE 0
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. '9
6-4�/ Teem
Dist. No County h�%f�� }age
ArC y (It cit}. a street address)
Name of deceasedMaa�H;
de; Single, married, widowed, " "
Sex . Colo /hGts or divorced (write the word) V�*-4-4,46 Date of Death 7/l4-7) • a 19 `
Age Y., .rs ,t etinths 7 Days Birthplace m e-,. ` . y,
Cause of Death. .. ... ... ................. . . . ... .. .. Q
Certificate was signed by !�; ��,yt, ai.1✓
Address +r�� ../ = -s�i' /ram-�-c , , p- y
Place of Burial (or Removal)..e ..L,<1,! „.e / . 3
(If body is to be/ppo rily held,fill in space 1st c�
Cemetery.... Date of Burial 0-7)- 4.3 `,3. 19..04
(If body is to he tempor .ily held, till In space later)
The Certificate of Death containin above sta ed particulars, having been presented to me, after careful exami
nation. th ante appeari to PLE E, CORRECT, AND SATISFACTORY AS RF )CIRED BY TAWI have ac e ted the sam f re 'st tio;,/:ve recorded it in my Lo Record with the above stated Registerei
Number, don the b e . '" GRANT A PERMIT
to I ��I 77 )2 <7.
a e) Address
the to hold tempera it t ody
dertaker or pelson having charge of corpse)
, r the is to h
Dated 19.03. (Signed).
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subje to Inca
cemetery or other regulations), unless removal is by common carrier. ;., ,.,l,;,l, .... . T.,....:s no....:. !VC M. a9\ .. -°a
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