Barber, James Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to 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 B CK INK. Registered No..._...il
!,�! )-y�+�Qa Town
Dist. No r', . �County (/J • Village
( 0,gives t address)
Name of deceased
:row w Ingle, married, widowed, •
Sex Color divorced (write the word) Date of Death !� )% 19 GP
Age Years 7 Months .,...Days Birthplace gali:f ,re•f..,�'j..9
Cause off Death /
Certificate was signed by 1 M.D.
...Address ,. :2 7
Place of Burial (or Removal)
(If body is toMergUr held,fill in spa ter)
f}P� Date of Burial....e r 2- 19..t
Cemete ... ... . .(I!body ieytoorarily held,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
Number,J d the be is • REBY GRANT A PERMIT /'Z_,_-- t L � r '
to I ( r .. �iL /�„
e (Address) /�
the .. . to hold temporarily and the body.
(Undertaker or person having charge of orpse) (Inter,rem991 o .oy�ewlse o!(state howl)
Dated ;r . .—i!r..././ 19.r .O (Signed) - r,...11 , �-�
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other resu_.:lions),stales/removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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