Johnson, J Edevin I orm % .61. NEW YORK STATE DEPARTMENT OF HEALTH
e 0 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 CERTIFIyTFy..OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. ac�/z/
Pcr
Dist. No•�1/ County �%../ ezteAzA-Q�c-c./ �
0 or y (If city, give'street address)
Name of deceased ) . ,
le, married, widowed,
Se _.. t/
� ZColor '-�'`�o divorced (write ja e word) Date of Death..��...3 � 19..CI
Age•••f..5-.6. Year.....,/ AZgntlis o Days Birthplace
Cause of .Death.... ... .
... ....
Certificate was signed b •• .. .... ® M.D.
Address ,
c -/Ve<-- a
Place of Burial (or Removal) '�G. A.,�.
(If body is to be temporarily held, till in pace later) '
Cemetery „A.--�.e.--` ",..!-E4.4,`�' Date of Burial....'�.��•{� 6 19...1.'�.
(If body Is to he temporarily held. fill 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 he 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
Number and on the basis rear EREBY GRANT A PERMIT
tot-'''-'-f---/
-� � ��' ., ,
the••• . to hold temporarilyn � th od r.
e er o erson - charge of r �� I em ve,or other • dis'lo [state how }Date 19.:.. (Signed), . -,-
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subjec to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is requi ed.
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