Gasperin, Baby boy Formes.6L - 1,GHEW Y'O
K STATE DEPARTMENT OF TH
OFFICIAL BURIAL (OR REMOVAL) P MIT
ar This Permit can be signed only by the Local ;�trar (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 CERTW ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ft_._
Town /�/
Registered No
Dist. Net .d.� County �i!1:t' .al2,r Village ��� d '�1��..�
or City (If city,give street ad roes)
Name of deceased .... .... t,
Sin e, married/widowed,
Sex Color or divorced (write the word) Date of Wath / 19..& i
Age 4- Year Months ...Days /:irth I e.s -trt-s.Cause of Death _ '
Certificate was signed by -
Address
r
- .�:, .
Place of Burial (or Removal).."7� . .... k ,,ss..d
(If body is to esporarily hel 11 ace later) v
Cemetery. .. Date of Burial ,. . . . ....Z.,r 19.f1'.`�t
(If body is toporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented o me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for re ' tration, have recorded it in my Local d with above s ed Registered
Numberd on the s' EY GRANT A P IT
. . . ...... . . . ...
the . . .. to hold temporari,�. (address) the body.
(U er or on having charg o corpse) (In e,or se die {state howl)
-Dated.. .. ... ..19. & (Signed) �. .. .:. ..�
Re
This Pe .,it is sufficient for the Removal. (and Interment or Cremation) of a body to any of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit P 't (VS No. 62) is required.
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