Rando, James Form VS6L 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 CORREC D COMPLETE C TIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ;registered
Town
Dist. No....1,Q.1.... '' .• i jf Viliag:. a . cr• e-,
or Clt (If city,give ee ad ress)
N Hof d ased.... .. �.-. :..•• •• _
Single .m led, w1 wed, j'l' �-
ex r .or ced (writethe 1 ' CQ Date of e' 7-",47/.........,
1Age Years. . . . onths l .?: s BirthplacE.Cause of Death 'Certificate signed �y ` A. M.D.
Address . A ' ...
Place of Buri. ►- val) 1
(If body is to be te.•bra y hel, 1. :pace later) ( /
ary-
Cemetery. '.. .. ;fr .. ate of Burial '° ".. 19.
(If body is, .: emporarily h: fill in space later)
The Ce'ificate of D a containing the above stated particulars, having bee. • sented to me, after careful exami-
nation, the same pearing to be COMPLETE, CORRECT, AND SATI,A• - eRY AS REQUIRED BY LAW,
I have acc a sa e for registration, have recorded it in my Local : ord C . the alcove tated Registered
Number! o as' them .I HEREBY GRANT A PERMIT
to
tif" l
(Name) �- (�•ddresa) e body.
the to hold temporarily a.. . .... si
4.
nder or erson havin f orpse) n •�;• .v or otherwise a e s
Dated (Signed) i - '
Local Registrar
• Permit is sufficient for the Removal (and Interment or re.. on) of a body to any part of the to (subject to local
ce ery or other regulations),unless removal is by common • • , in which case a Transit Permit (VS No. 62) is required.
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