Clark, Clara Form VS.6L NEW YORK !STATE DEPARTMENT OF HEALTH
OFFICIAL I3URIAL (OR REMOVAL) PERMIT
or 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 D LE BLACK INK. t'
Dist. No Co Town _�'O
Village
w���' ` .,,— y or
��Cit, (I2 city,give street address)
Name of decease W'�..`
Sex. Color or ivorc-d (write
Sind le marries,rite the word) Date of Death ..a�.t:c,e..�,'� 19'3
Age Yea Mon Days/.?1, -o . Birthplace
Cause of Death..:: .fArriw r^t..._.�z _
Certificate was signe by .. �r/,< 1 T M D.
Akidress f 7 r fit!.. .a+'4.• -
Place r Burial (or Removal) ,, . �,,, �'�-
1
us bod;-is to be temporarily held,fall in space later) p
Cemetery Date of Burial r......V. 1"7
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the a ove stated particulars, having been prese ted to me, after careful exami-
nation, the same appearingto be COMPETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hay- '.;a.ted the same or trati have recorded it in my Local Record with the above stated Registered
Nu...'� d cag e th .�• 7EREBY GRANT A PERMIT 4,4 N-
to... �� / %
f (Name •--� �� dress)
the �"`�`'l"�� ' to hold tempora '1 the body.
r or ygpeon havingc f corpse) move,or othe dispose of(state howl)
/"/ nsrss p rp
Dated.... 4w• 1907 (Signed).
Local R stray
This Permit is saf+icient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regu:-bons),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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