Tupper, Robert Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
� OFFICIAL BURIAL (OR REMOVAL) PERMIT
Or 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. Re istered No. ,7
// --mown -°
Dist. No �l...County... Village 2 Gw--e_____
City �/' (If city, give street address)
Name of deceased .. �//
Single, married, widowed, y�*%ref -^
Sex7,Z Color or divorced (write the word .. Date of ' 19.
Age . . " Year ... ntl / Days irthplace .. .... . '' r
Cause of Death ��¢%�'1.0"`' ,,,ate..
Certificate was signed by ... „ , , ... M.D.
Address
Place of Burial (orov .... tif/"�'�
(If body is to be temp, y held, 11 pace later '////
Cemetery ...� Date of rial L.... 19,7`
(If body is to be tem.orarily held.fil in space later)
The Certificate of Death containing the above stated particulars, having been press. ted to me, after careful cxami-
nation, the same appearing to be O►ZPLETE, C ,•RECT, AND SATISFACTORY AS.- REQUIRED BY LA\:R,
I have accep e. the sam fo re c�, / i. /., forded it in my L cord with the abov to Registered
Number, a.y. .n the s er=- - ' t •
to i �i� OW�� o, B i% ANT A PER
(Nathe 4 to hold temporarily a res dy..
(II or .erson ing charg• ..•) n ove or otherwi oo s to ho
Dated `0 19 %�fe (Signed) • ....
Loca egistrar
This1ermit is sufficient for the •emoval (and Interment or Cremation) of a body to any part of the State (su ject 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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