Mabb, Arthur Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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........_...................
Town —
.a _
Dist. No... Co ty -,.,, iliege
j
O (If cigive street ad rasa)
Name of deceased
/ , � ®,, gle married, widowed, - �!i a
Sex�'a"'"'-'Eolo divorced (write the wor Date of Dea 19..1'�6
Age '..'...?Years Months.— Days • pi:440 •
Cause of Death •
.t �
Certificate was signed by '. M.D.
•
Address
Place of Burial (or Removal- -Y -j t �(
(If body is'to porar h in apace 1: ) O
Cemetery r .-- e' � � «� Date of Burilke-y 'Z 1 U
(If body Is to be temporarily 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
N d on the sis ereo I HE�GR y./T A PERMI -G� &J
to.. -CX�u ;;�f//
.. . ... ....... . .
-c
(Nan ,-,.,.� 1 .,.. -. (Address)
o hold temporarily a the body.
nde lter pe a having charg o eg r rpse) {% Inter,remove,or wise ,o [state how))
DateCe
. 19.77 (Signed).�
Local Registrar
This Permit i sufficient for the Removal (and Interment or Cremation) of a body 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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