Ramsey, Thomas Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT /`1)::
This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District own,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered
IN
(; /ewn ,� a n
Dist. No "County "'`TOGAllage •
`� rl , N�...�
City (If city,give street add as)
N of deceased
�fj. Singgle, married, widowed, �C% Zr
Sex 0;r.Ze" r divorced (wri wor .Date o .... ... ...�,,., 1Age ear j��4
y,r. .� nths s Birthpla
Cause of Death ,
Certificate was si ed by 7) ... M.D.
Addre .. ..
E0r
held,flII .., Date of Buri . 19 ["��
(If body o be temporarily eld,fill in space la
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation,*the s. 1.p.earin_ to be COMPLETE, + 'RECT, AND SATISFA ORY AS REQUIRED BY LAW,
I have acce. .�• .. F r regis., tion, hav- . -.riled it in my Local R /d with the above stat .`' gistered
Number, n�0,a thereo H tE$ NT A PERMIT �, �%
(Name area_��i the body.
the 1 ar . :•4 old temporarily a.•. !
(Un•y ,, •e o_ . _ c,ar_ , orpse) Inter,rem r _ , -pose of[staff how]) /
Date. f. , .. R. 19 ./ (Signed) �-
Acl Re: strar �111/ / eel
1240 This Permit is sufficient for the Removal (and Interment or Cremation) of a boil, o any p - ••• ( <• ec •
cemetery or other regulations),unless removal is by common carrier,in which case a T snit Permit (VS No. 62) is requ'
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