Mead, Stephen Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
123' 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 CERTIFI,,, T§OF
DEATH, LEGIBLY WRITTEN PU r ABLE BLACK INK. �iR_egist e No. 7'
Dist. No..,. �t.Q./..County -- " elt/C 41-• }Tweivou �!�• i�
ltv (If city, give street addres.
Name of deceased �._ � •
j ngle, married, widowed,
Sea!!/ Color..) 4.1- 0- divorced (write the word).... Date of Death 1.5" 19 Y. �=
Age D Year 0 M the ... ...�Q Days irthplace.,r�s�2. rtC• Q " 40
Cause of Death . . ... ... /.40
jr i
Certificate was signed by R.C ....7:41�..4,416.0t t.. ...71..7, AP _ _ M.D
Address i� �J! ,c .. ..,,' ` 4 . y
Place of Burial or Remov l) ,�.,es,4tt. ,( , -.l? , .
(If body Is to b i t oratily h fi'l in spat ter) /
((((((JJJJJJ �j ,/
Cemetery....— e ..4) C.�,aQ,,t?'1.* Date of Burial ��� !/ 19..,.$4
(If body Is to lie temporarily held, nli In space later)
The Certificate of Death 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 pted the same for registration, have recorded it in my Local cord with the above stated Registered
Num , nd o the b ' t f I H EQ,Y T A PERMIT 7 .
to I s er q, C: . - - � ,
the to hold tempora -1 nd.... the body.
(Us to er o person]laving charge o corpse) er,remove, wise d' a of[state ow])
Dated... t� 19.. s' (Signed)
Local Re strar This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( ubject 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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