Bonitatibus, Thelma Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIJ. L BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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....... 2'_J_ .....
Dist. No o I County 9" +— Town Village 4 32414r.,2 - -1
Cit (If city,give str address)
Name of deceased f��... lt�via-:..a-- o .4..c,
I Single, married, widowed, •
Se-s-'--eM.Ge��..Color.w .or divorc-d (write the word).:..!u f D to of Death . (71 19 J-
Age....,2.Q Y arsfionth Da s T ' '
Cause of Deat .Yi.. i lvfek ., ...9C�. . 1i.,,
Certificate-was signed by e ..• Ems,,,,... M.D.
Address 40
` 2.z. e. #1.. n ,,• ,
Place Burial (or emoval). Qi,4 c/ LL/Gl/l,,{4,,,.•C.x.. v-[�,.. d.
(If bod-is to be tempor'y hel v l I a space later) 11 rr,,,,,, - .
Cemetery ..i ' •' Date of Burial....(4 . , 9 - 13.
(If body is to be temporarily held. ;=I in space later) .e
The Certificate of Death containing the above stated partihulails, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTOR,Y A REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record wife the above stated Registered
N ber, and o the asis thereof I HER G A PERM
(Name) � � � 1
the to hold tempor. i1, Aora the body.
( ndertater or pe King charge o se) (Iut64,remove,or h ..e dispose of[state how])
Dated...��l.�.Q.G.A 19,E (Signed). f., ... z ..
Local a strar
This Permit is sufr^.isnt for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regi,.. :ions),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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