Benette, Joseph Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
for 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 CERTIFICyjI.TE 9F
DEATH, LEGIBLY WRITTEN IN DURABLE BINK. (p �/
Registered No.
� To�cx
Dist. N li.�!/..CountyZ,' Zci.iA_1 a �¢) �/,
-/1.4to..,,,.,,,,,,,se...r C �. (If c' give s>r ad�lresNr r .�
Na eceased /.s/"�
. 7 , married, widowed, -�•
Sep:. . . . .. ... . .... ivorced (write the wor .. Date of Death... �Q.,../ r 1Y'C
A . ' rs ... ....6 Ma s Birthpla
g��. .. . - . ...Days p
Cause of Death ,h rl�����rt,1e.-
Certificate was signed i . , J.......AO_ • f M.D.
Address / _.CV r. ... •
t .
Place of Buri ( Removal)._ ,,�R,,
(If body is to be a orarily held, fill space later)
Cemeter Date of Burial r ..rays, .r' ZP 19..E
(If body is to be temporarily hel ill .n el ace later
The Certificate of Death containing the above stated particulars, having been presented to me. after careful exami-
nation, the same appearing to be C PLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW,
I have a ,ted the same for egist ion, have recorded it in my Lo 1 ecord with the above stated Registered
Numb don the b t reof ERir Y NT A PERMI � ',
... .... . .. .... . . ... . .. . . .. .
ame (Ad /r
the to hold temporari and he body.
(IInd r or person ha r orpse) • r, remove, erti . d" of [state how))
Dated . .... . - ' 49 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Intermen or C mation) of ody to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which c e a Transit Permit (VS No. 62) is required.
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