Green, Anthony Form IS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Vr 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....orlf
Thwil�
Dist. No. GO ...County VCH►age... ' ��
t1F itv (If city, give street iszoa dress)
Name of deceased
�,/, . mingle, m rigid, widowed,
Sex A _Color.Or al-a.or divorced (write the word).. . ... . .... Date of Dea . �� 470 �,119...s+5
Age Yea '� onths Days Birthplace *` =u�A -76:�e�....C� �.
Cause of Death...-4G9 i+' '
Certificate was signed by._...._ a_.. .y... J.t...t� c M.D.
Address y/ ... . . . ..,....
Place of Burial (or Removal)...7 L 4•.�:t!.. .t.l?. /.
(If body is to porartly T
ir i,ii in i later)
Cemetery 4 /}� Date of Burial aJ .�' 19....�
(Jr body 1s to be temporarily ld, i1 ,n space later)
The Certificate of Death containing the above sta d 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 ', and on Ay basi thereof I HEREBY GRANT 'A PERMIT
to...gIfik '4°11r. . 7'
(Add
the to hold tempor i nd the body.
(Under e o pere n h ving charge of corpse) r remov ,o of erwise a of[eta how])
Dated , 19...`s4'$— (Signed).. . �'�� ... .....,�
Local Re is rar
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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