Bentley, Ernie Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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. 4 ,* 'Z>
� �(' Town
Dist. Na f6�7 County.b .. n ....
. ��11 or—City (If city,give street address)
Name of dede,„±0.Att
ceased e
,, ` 0..4„,Single, married, widowed,
.4 Se eC.ColorLE/ er divorced (write the word). .. . Date of Deat(i. . .•..17 19.J6
Age . Years....�(.s.6 Months l Days Birthplace..
/
Cause of Death -- in. .. ,
Certificate was signed by __
Address
Place of Burial (or Removal)..r.61Arr d... . h t
,,k,r,•„
(If body is to be tempora y held,fill pace later)
Cemetery Date of Burial....
(If body.is to be tempo y held,fill in space later) tyt1311)24• ai 19/
The Certificate of th 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 b ' then f HER Y GRANT A PERMIT
to...
/� � (Name} ress) �.. :.i
the „:.•..1`y•e LA..I .r to hold temporarily and the body.
( ndertaker or person having charge o corpse) (Inter,remove r oth dispose of[state how])
Dated ..4.01— 194A ?
(Signed) ... aO. ... :► �� '
omit is sufficient for the Removal Vacal part Registrar
This o
(and Interment or Cremation) of a bLrdy to anypart of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required,
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