Lennox, Thomas 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. gistered No.
Dist. NJ.C-5' County.., 1 Town
Villager:.
(If city,give St ad seas)
Name of deceased ----14".sne3.1.104.....cr-.,•,-c-:1-"frl'1-1•"-eity 1 “,..
-.., r.....&,... Single, married, widowed, 4i.„frf./
Sex.. . ,Y......Colo , or divorced (write Ar....word .erlife.'44.Date of th rje 49—
Age # '$( Years nths.4.,.. e,a2d./ :44 De4s ez.:444..... Birthplace .aek.vra.P't
Cause of Death
Certificate was signed by
Place of Burial (or Removal) e ,i. ..077d26. Carre-‘4°—&--- —C/ ,
(If body is to be rarily held, in sputter) .d ar
Cemetery .. .... ..... 41.--1/1-t
/ Date of Buria1.0-4‘ • 4-7
**,
(If body is to porarily held, in space later)
The Certifi e of Death ntaining the above stated particulars, having been presente to me, after careful exami-
nation, the same appe n to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have r ccepted e or re ' tion, have recorded it in my Local ecord with the above stated Registered
Nu,, , ', ion I HEREBY GRANT A PERMIT
ev,/ ( ress)
the. fr.41,--1•I'l to hold temporaynd the body.
(UCZ2aellter or pernring charge oore) .. (70.,r ,or otherwisi din ts in)
Dated 19 (Signed) .
Local Registrar
This Perm is sufficient for the Removal (and Interment or Cremation) of a body to any part of the (subject to load
....,.....,..,.. ..... nt ay rainsIntinnal.unless ramped is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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