Hillis, Jane 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
Dist. Nett51 l 4.).41./V1-4-4-.4....,--County... Village .... y
City (If city,give street add )
Name f deceased t.R..i Atect-tr-ti..-7Burgle,mafried, w ,
Ser�iColor or ). Date of th. IA 19
Age.../qq Y Mon s. Days • Birthplace...
Cause of/Death... ... . ... ... . .. .
;: w
tias si " by ------ ___--—— .-_
ss .... .. .. � �• �ce ' 1 (or Remova .. .... ..
(If body 1s to temporarily hel in space later
Cemete Date of Burial.. . .n....1...7y. .193.
1
(If body is to be tempo.41.4.41W...
held,fill in space later)
The Certificate of Death containing the above stated pa ticulars, having been presen d 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 • ation, have recorded it in my Record with e above stated Registered
N , and on th bas1 •�h EBY GRANT A PERMIT If A �
to....
:me) i ress)
the. .. f to hold temporarily and. the body.
(U e er o ersonAsring charge corpse) "later, •••� r o er pose oy
wl)
,Dated.... .:�. p...1..a1 19.. (Signed) 4� t
/ Local Registrar
A This Permit is sufficient for the Rem val (and Interment or a body to any part of the State (subject to local
,....... e ..s .. . ..s6.. .. l. n...... 3i .l_maws ramne d is by en/ninon carrier.in '-ich ease a Transit Permit (VS No. 62) is required.
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