Jarvis, Stephen Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
/a 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 CERTIFW3TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No..__._
Town
Dist. No.: .#.L.I.County aiR..:.r.! !-C. .r Village... rardten.. 2,t y...ddle,,) `� ...
.�L ��jty Of city give street address)
Name of deceased �e1 -2/
Single, married, wido .
Sex . .. .. .Colorjut
. .. ..or divorced (wr4e the word) ■G�...� Date of Death.„g.'t'Qi4e-L .! 19.., .
Age . ,�l Yea�3 . Months b Days Birthplace...2 6na...4-at% U,,fic s
Cause of Death.....L;rArf-t!�n
Certificate was signed}�' ..dl. - , ,l M.D.
Address ,_
..
Place of Burial (or Removal) .. . . 4•
(If body Is to be moored y held, d In sp c later)
Cemetery + ..,�j n in u .. . Date of Burial.... .. 9 19...5
(if body le to be temporarily held. 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
gr„6yt �R jJ FREBY GRANT A PERMIT Numb don the s t e— H f Aa �-eat
.�,�
.. ... (Add ../r�% •
the to hold temporaril a the body.
( •o kcr .r prn Wr�Dn b ring elm a rose) ter, a of e a (state bow])
Dated E/ 4Vor ... 19.... (Signed). ./. . .
L al Regis
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any p 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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