Foley, John g t it
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 CERTII9C_ TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. �j
Town
Dist. NArcliCounty ," t..; :.,. ge ` '►"?! �!g Sorinsrs iv
{(/ (If city, ci,-,'Str•7:. JI r0us k
Name of deceased °6�
_ingle, married, widowed,
Sex Colc ... ....or cliv ' (writ the rd Date of T) ..t};. ! !r� _�Q. ':✓ �
Age �' Years the .`.�/ays . Birthplaces tr
Cause of Death A
A/
Certificate was signer by .sweeleAto•""°' ',I D
Address
Place of Bur' (0 .! o-.. .o , .... .... Q ...��
(If body Is to m rarsily bet, fit spare Ia r)
Cemeter ... Date of Burial. . Sr' 194
,If body Is t be be temporarilyel�apace 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 REQLTIRFD BY 1.A\.V.
I have accepted th s e for registratio a r: orded it in my Local Recor • the above stated Registered
Number, and on asis t ( P If ANT l
to / s�
(. me) yrrilegr (Ass)
the
.... temporarily a ... ... .. ....the body.
(find a er erao • -Ing charge .irpse) (140,ret ve, erwise dispose of state how))
Dated 10 eJ
T (Si n,d)
I. I R s
This Permit is suffi ent for the Removal (an Interment or Cremation) of a b� a� t to local
cemetery or other regulations), unless removal is bycommon carrier, in which case a Tra si Permit VS N 6
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