Perry, William Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFIC?L..L BURIAL (OR REMOVAL) PERMIT
to 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 i-cfter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
' yR�1.°1-Registered No...3.Z. .__...-_._
Town 4�' '4 �-,1f /
Dist. \To.��t.0..l...�county .t�✓.� �Ak
` Village. n `
•
/� /� or City (If city,give street address)
Name of deceased /���zada ....Oe r
, _ Single, married, widows ,
Sep:.ksat..„Coio:.....Tivt�,..or divorce (write the word) r Date of Death • .7i 19..?i
Age 41- Year- .../.e? Mon ./...� Days Birthplace, tanLa.,./..�1.•.r
Cause of Death . . v4i•- �c %+..•C.. r- es-:.ice.- /Oygq!zeZe
Certificate was signed /� //.i-/. f • 4 d2Li. .s M.D.
^_ddress 'i �7L.�lIr� .^. . ,�.. r/.'r..'"�..
Plac; ` Burial (or Removal) /�-( t-t"�i, Z
. /.'..f I
(If hod:. Is to be tempowilz beld,yp1�1 in spa later)
Cemetery , rten.c.le(-.-S..'.c.,/.. Date of Burial • G/ 193
(If body is to be temporarily held.Ell In space 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
N a' ���umber and on e a thfreof I HEREBY GRANT A PERMIT
/ .
(N me � _,�t (Address) T
the to hold temporari y n the body.
(Unde er or pe�n awing charge o,f corpse) , remove,o o erwise dispose of[state howl)
Dated ....[gi 19..?.?:.. (Signed)... ..: .. ...
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regu.. lions),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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