Lemery, Leonide Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
:JrThis Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or Cites 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.
r
Dist. No��'�I C untyaleite
TownVilla
or Cl (If city,giv reet address)
aZe
Name of decea
gle, married, widowed, �-s
S9t�l�.0 .Color, ." divorced (write the word Date'o eatla -ix..- 19.414
Age..6Q Y ars...a Months /2- a s Birthplace 40 'IFr.-.s�+...a
�3 i
Cause of DeatlakiFl % ..
fr
Certificate was si a -. . ..% . M.D.
Address. y am...-
Place of Burial (or Removal)... . ..
(If body o tempo r' Id,fill in sp ater)
Cem Date of Buri�P edi.....5-- 19.1210
(If body is to be temp arily held, fill In space later)
The Certificate of Death con':'ining the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing t,, 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
Nu er, and on a basis th f I HEREBY GRANT A PERMjZ oyQ`
/yt� ( "" (Address)
the '11l1?.'9 to hold temporarily and. the body.
LI1nde ker ow ers having charge of corpse) n ,or otherwise dispose of[state how])
Dated,(.. 19. (Signed) .
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 regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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