Guyette, George Form Y.S.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tow .
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFVE
DEATH, LEGIBLY WRITTEN IN DUR LE BLACK INK.
Regis e No.
n
Dist. NS66/ T-etcy County. a61-41-"----- V (re / 14. •
• y (If city, give street address)
Name of deceased 4(-' • •
:.-_•iugle, mar d, widewed, - I /
Sex'-'31( Color. .c,,- 61orred write the word) . Date of Death.... — • ts-/
Age atO Year..... ont, ont if- ys Birthplace re-- /,'
/- / -
Cause of Death .
Certificate was signed by.. .... .. ee--P-4.1---1-,- --' M.D.
"' •"• ••
Address . '
,
Place of Burial fr/em I' Itr- I
11•,- rss'17-
(If body is to be ten .. ! ly , i s ce later)
Cemetery II Da of Burial 3 19.4
(If body is to be te p. arily held, ii'. It.space later)
The Certificate of Death c ntaining the above stated particulars, having been presented to e, after careful exami-
nation, the _.me appearin to b CO PLETE, CORRECT, AND SAT[SF CT Y A REO 'IRE' BY LAW,
I have ac - ed the sam or r gist on, have recorded it in my Local
i *th th ye Registered
Number, . , .n the t f Y GR NT A PERMIT,
to A,
the 411, e)
to hold temporarily an d ss .
.Ille body.
(Under r p on7ng charge f e) ove,or othere dis o t i)
Dated 1 (Signed)
Local Registrar
This Permit is fficient for the emoval (and Interment or Cremation) of a body to any part of the State ( bject to local
cemetery or other r lations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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