Viele, Sidney 1''Orm VS160.61. wio-sz-aa.wro (It-5ZUDJ
NEW YORK SMITE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
SW-This Permit Can be signed only by the Local Registrar(Deputy or Subrreegqiastrar)of the Primary Rrgilttra-
ti6n District(Town Ville or_ in whichthe death occurred after the FILING and acceptance of a CO
D R-
RECT AN COMPLETE CET R TII DEATH,I MGM V WRITTEN IN DURABLE BLACK INK,
Dist No..,,,, -74_J... Registered No._.:--.--.-_....--.
County._,.. .-- Sea. Date
of Death---�=- iK-=_--_.��
'tali" -- Age__ . __-Yrs. Color_
oit)r,give street address) ( .)
Cause of Death.......___ ..
Place of Burial(or R )---• - - - 1 0 ,
F netesy fi' w__- Date ofBurial_.22 r 11 '1)
ZCertificate of Death of. v r .. __ ,_._ a
(Gi ull same of 'deceased)
having been presented to me containing ;{above stated particulars, and after careful examination,
the same appearing to be COMPLETE, ORRECT, AND SATISFACTORY AS REQUIRED BY
LAW, I have accepted the same for registration,have recorded it in my Local Record with
the abo stated ter q N 1tn�er,and on the basis ereof I HEREBY9RANT A PERMIT
to:.. }r•
(N e of ) , .C--- (Address) r r
tile...... _... . .... ..._to.-. s.ct ..4![L.__ th body.
u or wing charge of corpse) (Inter,move,,p�of ise - to how
bated---- ._ 19ds2.. (Signed) ` i 41
Local Registrar
This Permit is sufficient for the Removal (awl Interment or Cremation) of a body to any part of thee,
- State (subject to local cemetery or other regsdation),unless removal is by common carrier.in which cabs a
Transit Permit(VS No.62)is required.
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