Rando, Edith Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ta 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...___.__...______._
Dist. No 30?I/ County Village
or City (If city,give street address)
Name of deceased izt-7.7.---7E-xv
i Single, married, widowed, -7A
Sex.. - -Color...CA/ or divorced (write the word). .Date of D th... ,... , .....19
Age $V. Years 0 Months 4,2 Day place .,
Cause of Death
Certificate was signed by ?fit`
Address . 1 e,..... .,.....,...,�,.............,...._M.D.
.. . .........
Place of Burial (or Removal) �o-^-�'n �c� .--ff
(If body is to be to p rarily , space later)
Cemetery .... .... .. . Date of Burial n. ... .. `e— 19.39
(If body is to be temporarily he ,fill 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
Nu . ; , and on the basis thereof I HEREBY GRANT A PERMIT
( e) - , , ci�:ddress)
the ...... to hold temporaril and +_.:v the body.
Wade or person having charge of corpse) (Inter, or oth e die of[ to w])
Dated • R.i 19..E9 (Signed) ..a.:c..i..clst.E � ,,,
Local R
/
This Permit is sufrcient for the Removal (and Interment or Cremation) of a body to any part of the State (subject o local
cemetery or other regu.,lions),unkee removal is by common carrier,in which case a Transit Permit (VS No. 62) is req .
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