Ferguson, Ella Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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..cft/
lawn
Dist. No.....t/..z...County. Arrtifere,44.-- WHage 0.??1'7 felf-44e,"..eva- Ato 7?- . 1'2
...___ „....--- or-City (if city,give street address)
Name of deceased ffeete 74.
. 1a
., Single, married, widowed,(/ -.,,,,1 •
Sex... .71rAt....Color.. ..kAor divorced (writ the word).--4"7" Date of Death 4.?" "1--"41 19 r
Age ffia,2- Years 4onths, 6 - Days . Birthplace be-e-6414' •z• ‘c
Certificate was signe by 41 M.D.
Address 4,44,e-e,,..." sr."-Z, >,-"! - -Place of Burial (or Removal)...1.444470e,' X .0...• `,' ‘,.:2e,ere...,i //
(If body is to be tenorarily held,Sill spec ter)
Cemetery Z`"•" Date of Burial.. 19
,
(If body is to be temporarily held, Oil 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, a=h bta..th f HEI2BY GRANT A PER1VIIT ,, /-(: ..ee. ,.)4. v', iiie..60 ,-- z
-,t./ 7,2"Z )7 to ,.- -
e) (Adress
the to hold temporarily d , /- body.
(Uncle ker or verso having charge,9ferpae) er ve,or otherwis no.•',..it state
Dated // 19.7- (Signed) ir,--
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subj ct 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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