Bosley, Emery 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,
Wine, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DU LE BLACK INK. Regist NoeS...7............_
Dist. No. 0/..County , Aliitage. 1.3 7 ,-/,,,,,..e..,,a1.,
City (If city,give et t address)
Name of deceased
Single, ma ed, widowed, .
Sex. ., , Color. a..4..gr divorc (write the word) ate of eath ..iy. 190.,
Age 6 7 Cause of Dea ..thixts,e4j. Months 10 Day. Birthplace '7/,
c4,4 . ... .. . . .
Certificate was signe , ..-2.;/2.61 .7 . •
.... .D. I
- u
Address
Place •f Burial 0 Remov .. • •
• vS eireitCLatl ,?gie.0,) ./y
(If bodr is to be -lo, rily h s later)
Cemetery.... etir•ff Date of Burial e0e-11--a-44-/' '''?,- 19.S
(It body is to .e temporarily held,fill space later)
The Certificate of Death containing the above stated particulars, having been p eented to me, a er careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFA ORY AS REQUIRED BY LAW,
I have ted the same for registration, have recorded it in my Local Record with the above stated Registered
Nu and on th • therp..411j, HEREBY GRANT A PERMIT
t i-ta;seirCP-t/PLIC 8aleen( '
(Address)
the • to hold tempora ' and.. e body.
(1:1 er or person having charge of corpse) mo ,or .ijor" ds isedr...vize.....etate h I)
Dated 42 0 19....3.9 (Signed)
Local Registrar
Permit is suffrient for the Removal (and Interment or C a y to any part of the State (subject to local
cemetery or other regu.:=dons),unless removal is by common carrier,in ch case Transit Permit (VS No. 62) is required.
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