Meilleur, Emma Form VS.6L 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. Registered No..._..____.___
'� Tema- 1'
Dist. No..q.\$ . County.,/,[ Village - .. . .�l1 4.149 /7`.X
(If ciky, a rest address)
Name of deceased. ..t . ... . .. ... .. `
i
< .gle, married, widowed, /44 /� 19 f�
Sex rr.Color. .. ..... .. r divorced (write t word)/f/ ... .. .Date o e • /Age T Ye. D Months /. Days Birthplace '
Cause of eath..... .. .. ... �; �Fi►' j
Certificate was signed b •.. !'f♦ M.D.
Address - .�" �/," , ,./�/�� 4 .
Place of Burial (or Ij.e val /dilil,.i...' 1.. iir �` ` -
(If body Is to be tempor 1 ld . 1. .`*.a ) / j. z c
Cemetery �.��.%-... ....... r • . ,. Date of Buri , 19.�/P
(If body Is to be temporar'Ily held,fill in ..ace later) •
The Certificate of Death containing the above stated particulars, having been presented 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, have recorded it in my Local Record with the above stated Registered
Nun ¢r and on basiherepf HEREBY GRANT A PERMIT 4lece.. ,ypgr___ __e_t7
(Name) (Address
the to hold tempora ily and the body.
(U ertaker or person having charge c se) ter,remove,or of ea dispose [ ho )
Dated. rt / 'N.. 19.J. (Signed) .. .. ,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of bond o'any part of the State (subject 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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