Billington, Herbert 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, LLY WRITTEN IN DURABLE BLACK INK.
Registered No._....._..._..
,, Tawa
Dist. No-... 4' #.County.. e r Vie.. ,� . „t,,r
(If city,give,street a ss)
Name of-deceased.. ... .2...ed.-/eire---9
//,��,��� i igle, married, widowed, D
S Color..%/ r divorced (write the word Date of D tb ..� ....19.0047.
Age .17..Years) M nths .Da s Birth c . . .i�ir , .21,
Cause of Death..;.;:. .. . .. his
Certificate was signed b .r,4 11 D
Address;/.d.1 y
Place-of Burial`(or Removal) ..,tom— . . .,, ,.4
(it�dy is to re, h space
Cemetery...tors
:.. ..�............. Date of Burial Al .�Z::/ 19.c ..
%(If body is to be temporarily held,fill ins ce.later)
1
The,Certificate of Death contai ing 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, have recorded it in my Local Record with the above stated Registered
Num on th basis f I HEREBY GRANT A PERMIT
a
the •.. .. to hold temporarilyand the body.
(Undertaker or rson having charge of corpse) n othe s of[state how])
Dated ,e.L7 ,/,l 19.2.`j- . (Signed).. ...40.7..:''' � .
Local Registrar r
This,P • is sufficient for the Removal (tnd Interment or Cremation) of a body to any part of the (subjbct to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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