Parker, John Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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. Registered No..._. .Q.S.. ._..
Town .
Dist. No..✓4 of County Village b * i
til (If city, -ice street address)
Name of deceased
e, married, widowed,
Sep `/ ��KYColor... orc-d (write he word) ate of e 1 `� 46-7/- -2 V 94
Age 6..t3 Y rs t) o hs 6... .Days Birth lace. t
Cause of Death.... . ... .. .. .. ,,., „
Certificate was si .r- • ; .. M.D. ;
'_ddress -
Mac: f Puri (or Re• oval) `JP-7- y_ ... .... ...
(If bod•is to be t porariil t old fi in space later)
Cemetery.... Date of Burial ,119•34P
•• /
(If body is to be temporarily .fill in space later) t.
The Certificate of Dea,i. containing the above stated particulars, having been presented to me, after careful exami-E
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.s
I have a/pted the same for regis tion, have ecorded it in my Record with above stated Registered
Nu.. . and on the basi? reof ,HEREB NT A PERM
xa ) d 9>
the . .. . . .. .. . .. to hold tempor ly an e bod3edi
(D er r perso has4g chars.�f rpse) ove,or oivise is o state howl)
Dated -,X w7 19.i (Signed) LL./.t/
Local Registrar
This Permit is su°-ient for the Removal (and Interment or Cr a i of a bed to any part of the State (subject to local
cemetery or other regt.. Lions),unless removal is by common carrier, in w h case a ansit Permit (VS No. 62) is required.
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