Doty, Cora Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
CT 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 URABLE BLACK INK. �� Regis No.
Town' - if -
Dist. Ndl1.County .. .. �.::���+++,,, Village ....
X--
(If city,give st t address)
Name •f deceased../` - c
ii Single,married, widowed, �J�J /i,___.ai .7;
Sex. / olor. . e or divorced (write)helvordM.. Date of
Aged t."... Yt� F,L. r Most s -7-- ys Bi place �'sL. —;i .
Cause of Death....{..0.. .
Certificate was signed by M.D.
Address ...
Place of Burial or R oval) i Yf
-
(I1 body is to be poraril ld/,�fl1/]/Inace dater) n �` l fall op
Cemetery ��1 �C — ' Date of Burial .......... e fr/ 19
(If body is to be tempo y 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 ,.e for registration, have recorded it in my Local Record with the above stated Registered
NumJ �j�n :(�. 'sI H , Y ?/ T? PEP /�
(Name) tea se>
the �_ to hold tempora y a they
/taker or u�yyoa_�having charge c pse) ter,re ove,or o se disco f t h D
Dated - ,!�—a 19.t (Signed) .... .....
J Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No.62) is required.
IV
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