Bernard, Dewey Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
. 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.
`� �,,�/'
Dist. No..��‘7County.,w' 3-"-1 TownVillage
r Cit f city,give street address)
Name of deceased g��`
Ingle, married, widowed,
Ax71,4.Color/746444.,,
er divorced (write the word). Q ,1 Date of Dea 19. '
g Years Months Days Birthplace. w. --" .Cause of Death /..?4r . K!��t'
Certificate was signed by b'y' . �,. I— M.D.
Address.-..^c F^`" ! ..+eP .. .
Place of Burial (or Removal)
(If body is to be mporarily held, in space later)
Cemetery • y� p�j�' 7:, .Date of Bur' 4eL 10°5^
(If body is to be temporarily eld, fill in space later)
The Certificate of Death containing the above stated particulars, having bee 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
Nu b r, and on the basisLL thereof I HEREBY GRANT A PERMIT 7 . fi
li
(Name) (Address)
the. .... .. .:... to hold teniporaril and the body.
( ndertakeror personhaving charge o corpse) ntr„re ov ,or otherwise dispose of[state how])
Dated 19.Y.. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
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