Dixon, John Form VS.6i. NEW YORK STATE DEPARTMENT OF HEALTH `,,,i.P
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fl 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 INIC Registered No—../. ._.
�r o , jl Town / �._._..
Dist. No...9..1a1 County ' "c ORAL ►age
Sin le, m ed wid / orgy it city, glee street address)
Name of deceased
g wed, z •
..Sex... . . . .Colors. H!<Sti or divorced (write the word)...,r!�b Date of /D'e'ath 2. 19"
Age b.. Years Months... r3 a s , Birth lace ..kl/ .. . . . .r.0.2Jy.,Ga�- •
Cause of Death.. 4. y ` �p,,(�j • o>� Q,
Certificate was signed by `.,.,(: ... ,,e‘t M.D.
Address ) yy `' �' � ..y.. 1.
Place of Buri (or Removal)...
(If body is to mporarily held, till In pace later) (�
Cemetery.. --e-:? p • .ems.- w Date of Buriai...e0-Ce• y /6 — 19A-/[
(If body is to be temporarily held,till In apace 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, and on the basis thereof I HEREBY GRANT A PERMIT
to ilimiiii..itGcv A...a y.a.. .2.4 .i<<it.
(Naar) (Address)
the d..a./s''/ [ L to hold temporarily and a...;..,.•< the body.
Mafi er or person having charge of corpse) (Inter, remove,or otherwise dispose of[state howl)
Dated • / 2 194<.c2 (Signed) ‘fpy- �''�_ t..a r e.r.���r/y/�i?A1
(/ LOcal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b y to any part 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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