Lemery, Theodule i"rib 1.,. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Pr 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..-...1 .
Dist. •o..5 J 7-GtCounh- bt/ .......... 'pa .. ��" ' -"'�'"� s
.�� yge . (If city, give street ad,dress)
,t...7T
Name of deceased
'ngle, married, widowed,
Se kQ.�--('olor livorced (write word 4 4 4 Date of th.. . �..1,....19 '4i
pofC `
Age `� I Months.... ..... ... Da s Birthplace
Cause (If Death SS/I
'er(ilicate was signed by �7� /r M.D.
Address /�'
Place of Burial (or Removal r i�-ur>r ,,...f'j:.. ... .
((If body le to t 1 a y hel , till in space later t
Cemetery. .....�.. ... .... ..... ... Date f Burial /a. 19..
(If body to to be temporar y held. fill in apace later)
The Certificate of eath containing the above stated p ticulars, having been prese ted 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
Num17,11z asis ereof I HEREBY GRANT A PERMIT 'd2 '
to oQ��''
(Name) (Address) 7
the �'4.-� to hold temporaril and the body.
(1.7 ertakeror ersonlytving charge p;wee) (Inter,}},�� �ov oth Ise dispose of[state how])
Dated l r F 19 '� (Signed).
,ll'/
°cal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation 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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