Blackburn, Eugrue Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
'OFFICIAL BURIAL (OR REMOVAL) PERMIT
ter This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Prunary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTWIC OF
DEATH, LEGIBLY WRITTEN IN DU LE BLACK INK. 'Registered No-4 ._
-Town
Dist. NoA5-45 eq Count ce..."2"-e_e..44„, Arilldgk.- 3 1 ON-K-4.-- 1-at07<,
Jar Ci (If city,give street address)
Name of deceased (c:
,,, A • gle, married win' owed,
Sex.. 271....Color....(e.V.Ittor divorced (wr,ite the word) <--f-lir-44,r-e--144.Date o W f4,47'
Mon s ,../.7 Da s , Birthplace..
- -€14)10-rtee.,
- Certificate was--signed by.. ' - a,-..,..
Address
Place of Buri, ,.r Removal)... 4jaeVa..14tel
(If body is to b-A7 . 'orari e , space later)
Cemetery. ' Date of Burial 14-e-y it"- 19.31
(If body is t. be temporarily hel fill in space later)
The Certificate of Death containing the above stated particulars, having been pr nted to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFAC ORY AS REQUIRED BY LAW,
I havei: cepted the same for regis tion, have recorded it in my Record with th above stated Registered
Nu . .', and on btu' ther HE Y ARANT A PERM
L-7ezy2
to.D ..... . , I. .r. cat •
less)
the hold tempora • and t e body.
(rofertaket or person Ising charge of corpse) ,re ore,o erwise dc_,i1m).4e5i_ilee f[state de ow])
Dated.... • 19.,a r (Signed) (..{. -
. Local Registrar
Permit is lufficient for the Removal (and Interment or Cre a' ) of a y to any part of the State (subject to local
Ir
ceme 4 or other regulations),unless remove/is by common carrier,in w ich Transit Permit (VS No. 62) is required.
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