Norton, Effie Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL 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 after the FILING and acceptance of s CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No —
(� Tartagnee9
Dist. No. .7. Coun e 1 -.49—.4....14-4.4 .0-6-4-a,
. ,h, "° re'�
f y (If city,give street ad
Name of deceased i ..
Sing arried, widowed, •1
Sex. ...// ..Col . .or divorced (w e e wrd). .. 1 L...C.L)ate of e /a 19. ..
Age. ..b�„ Yea .� Mon s...O..� Days Wicte.iiisit*
Cause of Death ... •
Certificate was signed by A• M.D.
.. .. .. . .... /
Address 1.,9,/ ..��... . _ . ........ ...ZlG.r��Ta- . .,,
Place of Burial (or Removal) -P � 4K. �
(If body is to be temporarily h d,fill in ce later
Cemetery Date of Burial. . .... / 19.. .%
(If body is to be temporarily held,Lill 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 re ' tion, have recorded it in my L 1 Record ' the above stated Registered
Numb �d on basis th EBY GRANT A PERMIT X(ef4
to 1 ell e I.
e dress)
the.......e64 .4.... .. . to hold temporarily and . . the body.
rtaker or erson h ving charge 1 se) nter, e,o the se dispose of[state how])
Dated. .. . 19 L.? (Signed).... ... .....,....
4/,/ Local Registrar
Permit is sufficient for the Removal (and Interment or Crem 7.n) of a body to any part of the State (subject to local
...... ... ... mi... ..anh.linnal_imbues removal i by enmmnn carrier_in' hich ease a Transit Permit (VS No. a) is required.
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