Jerry, Emma Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No....._._.._...._.__..__
/ Town
/.,
Dist. NO. ,�aS..�S...Ccu?lty e,�,�..,,- Visage •
•�F? „l,.l�a+.�
0 (If city,give street address)
Name of deceased arvi_ear.s..,o►__.,
Ingle, married, owe
Sex 0eQo1or.... ' or divorced (w e thew d)....!(,44-.. tea,.) Date of Death... ..1...3....19..a.`1'
Age 7/Years...,, el Months ...3 ays Birthplace \ .....
Cause of Death '
Certificate was
signed by...' �, .P r
��.e.. _:. ; ,
.. M.D.
,4.ddress --u...a.../—
Place =f Burial or Removal) �+
(If hod:-is to be__slit
d, in space later) 0
Cemetery ����QQQ���i111/ . . Date of Burial -a u .� / 49 19..r3..`:
(If body is tobe temporarily he ,till in space later)
The Certificate of Death containing 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
Number,,;�t id the b� 's thea+eof I HEREBY GRANT A PERMITS /
Numbered
.,.......[ ame) , 7—.. ! (edare ,
the .. 4-� to hold temporarily and............;- .c )1'1the body.
d r ori�rson having charge ofG corpse) — ! (Intermove,or erwise dispose of[state how])
Dated .ems,. ,1.l� 19. ..G. , (Signed)..•!K; ' . .
Local Registrar
This Permit is sufr-lient for the Removal (and Interment or Cre`mattt�'Oon) of a body to any part of the State (subject to local
cemetery or other reg►.. dons),anless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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