Moen, Mary Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
112r This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (T wn,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF F
DEATH, LEGIBLY WRITTEN IN DUARAB B CK INK. • Registered No—. .... _.. .._.._
Dist. No..jCount �" RATOGA Town Qaratoga Sprin , 1
,Ti11a.. !
- c. (If city,give street address)
Name o eceased
. / / 0
ngle, m ried, widowed,
Sex divor d ( it: wor Date . 1.. ... ..y �Agehoylor.etir—S.
M :
�� .. _ .�.v Bit.
l'a � %�.... ,r ...
Cause of Death - .... . fr
Certificate was sign d . / ... .. e / . .D.
Address f �,
Place of Bur' r Remov 1 .... �J � ��
(If body is to orary he 1n ��/e;!�r� .. ,
Cemetery ... . . �. , Date of Burial... / od .... .
10
(If body 1 o e t m ora 1 in space later)
The Certificate of Death containing the above stated particulars, having be- pr-.ented to after caref exami-
nation, the same ap earin: to be Co • PLE , CORRECT, AND SATI• • %'.RY AS 'EQUIRED,.•' LAW,
I have accepted • e or re• . ••-tion, . ve record-- it in my Local • . ..with •e . •.• • ,r,'..stered
Number, and o. 7�App11061r,
/i .Y • PERMIT /i � . '
the //00r-
�,•'•. tempor. ��'!�! , g1� the bod .
,• rta/ or p •. •: _ o ., ' . r, ' .. ,or o; . • . .,f II . ..
Dat-. �,.-, �. 1• .. =1 (Signed)
. al 'egistr'
41, .
Permi is suf'lent for the emoval (and Interment or Cremation) of a an p '�' �.•i�tor
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