De Voe, Victor Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
a2r 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 .i
No.
Town '
Dist. I\To .. ..VCoun11ty... 4,Q114,,,,:y „ //
Name of deceased . . e_"Q-�Ll.. ..,. (If city,giv street address)
I,. , ngle, arried, widowed, J J,
Sex .} �i4.�..,,,..Color.. .... divorced (write the word) "" Date of th Yam/ • ,�.3 19
QA. ,
Age 7 Ye ..., Montls../ 7 Days --- --, Bi place ,
Cause of Death ,(j 7—
Certificate was signed ,� �! M.D.
U
Address l.. . i
Place of Bu al,(or Removal) ,
.
(If body is to , ;„p rlly hel `fill in space later)
Cemetery . .. ...a. . . Date of Burial 674-.., 02 6,, 19..`t
iri
(If body is to be temporari held,fill in space later)
The Certificate of ath containing the above stated par Oculars, 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 L 1 Record with the above stated Registered
Nuler, Vie b ' eof I HEREBY GRANT A PERMI
Name) — (Address)
the G to hold temporari) nd the body.
( taker or per�gn h vin charge of corpse) (Inter,�y;9ye,of o r `dispose [s how])
Dated.... .441iZ.1...I•C 19.... Z' (Signed)., . O�� f ---... .. .
,Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) f a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in whit case a Transit Permit (VS No. 62) is required.
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