Titus, Lena Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Car 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.
Dist. Na14`5/ County.leti Town— age
or-City- (If city,give street address)
Name of deceased..c? ` firms
Single, tnafriedrwictcnred, •
Sex Color .2'U' or d versed-{write the word Date of h 421/ v2 19.�/
Age.....`* .fl ars /O , Months I Da s 1 Birtliplac rr , ; .,
Cause of Death... . . . . . .. . . ... ... . . ... . . . .... ac e..
Certificate was sig}�eyl by .. .... .. ,F�i� 4�C M.D.
Address JL�=�-�
Place of Burial (or Removal)... ... ...... ....... .... .:
(If body is to be mporarily held,fill i ce later)
Cemetery... -'_— Date of Burial....,ed Y •Y 6 19..V./
(If body is to be temporarily he ,fill in pace 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 haveaccepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numb , and on e • siMt I HEREBY GRANT A PERMIT// i(f
(Name) (Address) 7r4-1-4 ifs)
the. .. to hold tempor ly and the body.
Iiiindertaker or person having charge of corpse) (Inter,
Dated.. 1). ....,A?..�t' 19.. ../. (Signed).. .. ..�2���-•s�cr
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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