Roblee, Nancy Form VS.61., -- . NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. , Town Registered No.
., e
y..?,42 .. i < �tx . _ .—.
Dist.
NTc�.�2,�.f:...Count .... ��-� •,:.2.--(:,-'
T �) (If city, give street ad es)
Name of deceased t �C,,. Veteran
{ (If eteran, ive name of War)
f Single, married;-widowed, --���� //
Sex Color....:2 or divorced (wri o}e word)..(rl/ ,¢ . Date of D ... 19.f14
Age Years 67 Months(writs
::.....Days Bi ace... G
Cause of Death
.
Certificate was signed by r .1... ... M.D.
Addressf <... , - AAA... ...t�G ,,,-4441,_
Place of Burial (or Removal) 1 „.. r.. ... �-
(If body is to be temporarily held, fill in space later) � f� y.
Cemetery - c....r.1. :..:a/G/ C . ,,)11,..,rr-- .Date of Burial . C, 2 3 19.. ,
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particult✓rs, having been presentq'd 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, ve recorded it in my Local Rec rd with the
�above stated Registered
Num 21,0-----
, and ott the basis the I HNT A PERMIT 7"�...
actress)
the.., . . ... .r.;!" 1 to hold tempora ' and.. �L...the body.
(tin ker • a ving charge of corpse) and.
,o othe w isnose of[state ow])
Dated - . . 1 19.. ... (Signed) .(�,.. e
Local Registrar
This Permit is sufficient for the Removal (and Interment r ' ation),'of a body to any part of the State (subject to local
cemetery or other reculational_ unless removal Is by commnn earrier in ,,hieh ca.n a Transit Permit (VS No. 621 is renuired.
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