La Lone, George Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
igr 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 CERTIFIC OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Regist ed No..J.e
Dist. No5J/ County.. Town `
�i1..1 Village.r,�fJ .. .Q/11c11
•
Name of de eased ��..
r City (If city, give s reet address)
Si e, married, widowed, s� ,//
S Colo .4
...o ivorced (write the word).' Date o /1.19.:1`,F2
Age 7 Yea •,/d Months l r Des Birthplac . 4.1,
Cause of Death... . .... . . ....
Certificate was signe M.D.
Address �- h. ... .. . .. . . . ... .
Place of Burial (,or Removal)..
(If body!e to be to ily I apace later) 1 19
Cemetery. Date of Biiria .D,CI�k.
(If body is to be temporarily d,fill in space later)
The Certificate of De h 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 accept the same for registration, have recorded it in my Local Record with the a ve stated Registered
Number, on the ba,s hereo J HE,' :r RANT A PERMIT
4.
the -%407,2 the body.
to hold tempo/ra/�ril/y)and... ..... ..
maker or on .a• ., .arge rpse) er remove,l the dispose of to how])
Date. . A. ... ..� 19. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the St to (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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