Butter, Roswell 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.
1 \ Town
Dist. No��3 �1 County_.,, Village.. . .
O Clty ( '. Give street address)
Name of deceased .(4-4-1,14.2e,
Single, married, widowed, ,/ • //
S .. . ...Col<'cu . .or divorced (write th vor Date of Deatf2. ‘ 196..
Age Years lontlis...../... ...D ys Birth 1 e
Cause of Death .. .=.-C„rec.,., '\
Certificate was signed by . . .. ... ..... M.D.
Address (72,�
Place of Burial (or Removal) , ... et.-- ..
(If body is to be temporaril•• le ,, till s •ce ter)
Cemetery rs 7 4 Date of Burial` . 2...t 1/e-C.
(If body is to he tempo y h•ld. tiI 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
Numb and on a basis her I HEREBY GRANT A PERM T- ,:t. ' ,„ , ,
(Name) Addres
the '''''l. . . . . to hold temporaril the ody.
( 'ndertaker or person baying charge of corpse) (In er(remove, �, : wise di• pse of[state bow])
Date / 9K.•7 1 .. (`igned) J .., =..�, .. .,'... ......-
oca Reg strar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part ;. he State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit S No. 62) is required.
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