Douglass, John Form IS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re 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 CERTIFICATE
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. 3
�.�-' ( " - .:...,
DrDist. Noa1�(�6 � County �lage City (If city,give street address)
Name of deceased",, I , t Single, arried, widowed, �f
Sex rv�... .Color ceci r di ced (write the word)+N. .. .Date of P,;ath.. . .. o 19/j
Age 11 Year Mon (o.... ....Days Birt place...�... ,o' -2.1y:.
Cause of Death i •
Certificate was signed by.... ... ).... M.L
Address �1 f
Place of Burial (or Re sv 6c-1,43NNfl
/ ---1\-i
(
lf body Is to be tempura eid a 1 ter)
Cemetery 4. Date of Burial /.3 19 ..
(If body Is to be temporanly ,eld,fill space later)
The Certificate of Death cont ining the above stated particulars, having been Presented to me, after careful exami
nation, the same appearing to he COMPLETE, CORRECT, AND SAT ISFACI ORY AS REQUIRED BY LAW
I have accepted the same for registration, have recorded it in my cord with t ated Registerei
Number, And on the basis thereof I HEREBY GRANT A PER
to -.i
> .Y
/ % "" ame) _ ( as)
the 's to hold temporarily an ..the body
(Undertaker or person having charge of_corpse) er or othe d e of(state j)
Dated .J`Y -- / ...19. rJ . (Signed)
Local Re strar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ject to coca
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