Brown, Jerome Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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...__._.___
Town IY
Dist. No �� alud[ly County Village
1 n Or City (If city,give street address)
..Name of deceased.. d��� ,tM..,
--yy,,.. //- Single, married, widowed,
Sex./.CI.J4..Color.. ..kLt�.tt..or divorced (write the word) ,.�trPC>G?� `G - Date Death...A .�2.. .3 19...9.8
Age.. .�..q.......... rs _ nth ..,3 Days Birthplacs),...=&.9....... .....
Cause of Death.... .. .. .. .. .
Certificate was signed b ... V.... .. C2;1.4,.. .,,.... M.D.
Address
. .. . .... .... ........
Place of Burial (or Removal) ..
(If body is to be temporarily b , in space later) �,, _ ^ t ,�
Cemetery v Q,A..1`,� Date o Burial..��.1 :. s,G.... 19"2
(If body is to be temporarily held, n in apace 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
Nu and on the basis therp� HEREBY GRANT A PERMIT ,
to
Y l�
C (Name) (Addre
the to hold temporar. y and the body.
r Eil ertakerr'or person baying charge of corpse) (Inter,remove,or dingrse die Z[state h w]
Dated.... .... .., . _ 19...3.. (Signed) �(. .\.�..,.. .. .. . . ... .
Local Registrar
This Permit is suu'cient for the Removal (and Interment or Cremation) of a y to any part of the State (subject to local
cemetery or other reg4. Lions),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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