Sawn, Jane Form ps.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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.._...........................
o , Town
Dist. Noi� 7.County V^r' . .. .. Village
Or City (If city,give street dress)
Name f deceased .6.S.. C.(�....... t
Single, married, widowed, `
S . , olor . . . ..or divorced (write the word) .. .... Date of eath.... .. jetfit.. 19.4'�.7
Age Y ars Mon s f Days Birthplace..
Cause of Death..:. .. ..
Certificate was signed b �i.. ++��,,�� M,D.'
Address �(!L.:.. s
Place of Bu ial (or Rem val)....
(I!body is to i jen�pp rp arily h ll in space la
Cemeteryi//A�.r/ri�Iv ... Date of Burial.... :... .vZ., 19,,7
...
(If body is to be temporarily held,fill 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, hay recorded it in my L Record with above stated Registered
Nu e , and on )4gsiaN
•
f EREB GRANT A PERMIT
to.... y '
,,,,,
the to hold temporarily and.... 4�� 1 the body.
(1.1941ertaker o ) ( r tb
Dated..... L ., i 19 (Signed) ... .
Local Registrar
This Permit is sufficient for the Rem 'al (and Interment or Cremation) a body to any part of the State (subject to local
cemetery or other regulations),unless rentslaal is by common carrier,in whi case a Transit Permit (VS No. 62) is required.
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