Losee, Dora 1
Form VS.61. 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN DURABLE BLACK INK. Registered N .2a la
/ T tg
Dist. No�(p0./ County... �� �silage / L�� �e 1�
�J y� OT City • (If city, give street 1uhlree )
Name of deceased XP4-'E-� �, a( “--
' � • Single, married, widowed, Cif
Sea: -mil Color d or divorced (write the word) ®®�� Date of ath `-'7/t1,,9�..��.�4r
Age �� .. . s *. Months 9 Days B' th lace ti ,o ' 74 �°.,• .4
Cause of Death.
Certificate was signed by 4:10141,44.44:gre•• • r„� M.D.Address V %4��G )�.-Lo,,.. 1 ...
Place of Burial (or Removal) Jae-el+r-71
,y.,., • `
‘i
(If body is to be p I held, fill in space late
P
Cemetery.. ... ..r. ..... �, . Date of Burial . L 19A
(If body is to be tempor rily,held, till 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 Lo. Record with the above stated Registered
umbe nd on ' basis ereof � BY GRANT A PERMIT
to � yt o 77
the to hold temporar' d. e body.
(Under er or erson ving charge o corpse) re e o hf�Ie d°• f to ))
Dated >e 19. #. (Signed).. .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su ject 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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