Dary, Angeline Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
•
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Cr 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 CORRECTAIPD COMPLETE CERTIFICJI9F
DEATH, LEGIBLY WRITTEN IN DURA E BLACK INK. .0..r c-- - .1' • Registered No. o? 4.- •
T--eywn
Dist. No4.-?"/ County a-)1?-"Ve4-.^... 3;414-age " 2f—e-',/ P7----/.
. or City (If city, give street address)
Name of deceased
i .
e, married, widowe , .
/ /,56-
Se .i . . ..••ol .... .... ... ,r divorced (write the wor Date of De. -144
' Age ., r Year Months. /2--- a ' Birthp 4.*
Cause of Death. . - .. / ,
Certificate was signed ) ..-- 4,0,
41'.." , A,1.,.c. io • \,1 I).
Address - i z.
' •T•eb -4 . - e•
Place of Burial ( Remov . - / /
,,,.
(If body is to be e oraril 1 11 in ace later) /
,
• Cemetery • i . Date Burial ...e.-.1---- 9 19.
(If body is to be temporarily held,nil in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, aster careful t.xami-
nation, th same appearing to be OMPLETE, CORRECT. AND SAT IS FACTORY AS REQUIRED BY LAW,
I have pted the same fo e tration, have recorded it in my Loc Record with the above stated Registered
. Nu , nd on the basis er I H • GRANT A PERM ,I trael 527—/ '
to. --
ame) (Ad
i the to hold temporarily a d th ody.
(ITn er o person,ng chargrpse) In , or otherwise " os state how]
' Dated. 19. (Signed)
ocal Reg
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject o 10 1
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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