Carson, Mary Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 RRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY W
Town EN IN DURABLE BLACK INK. Regi No.._ — _
1
Dist. N ... .County... .... .: ...
/, (If city,give street address)
Name of deceased /•e �r/./ .. :-.'1[f- (... ...
��` Single, 'ed, widowed, /f
Sex , ColaPea ..or divorced (writie h. word).. clG�rt�G�.cO' Date of 19.
Age....ol.r Years J Mo s ( Day !2!L.�L Birth ce
Cause of Death ..
Certificate was signed by D
Address
Place of Burial (or R:4 .l n t-�-
... ... . .
(If body is to be temporarily . '. space Is )
Cemetery v ..... .. r2- `� . . . . Date of Burial.. .. . . .....2 c�.6 19...c�Y
(If body is to be temporarily held,All in space later)
The Certificate of Death containing the above stated particul s, having been esented t 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 Local Record with the above stated Registered
Nu and on e basVh HEREBY GRANT A PERMIT ti �GA to
c:�J�'� a _ ddress)
the... ... C-i.C// to hold temporarily a the body.
ndertak r persgn ving charge co (Inter e, ethe dispose of[state how])
Dated... .,1 19... . (Signed) '
,,� Local Registrar
Permit ' sufficient for the Rem al (and Interment or Cremation �ody to any part of the State (subject to local
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