Phelps, Charles Form Vs.6L 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 CORRECT AND COMPLETE CERTIFICATE OF_
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.... 4...
n,/ T-ew_
Dist. Nos,a..Q., ..County W G� Vi}}age- /‘ '
f V.; ,r ^��r ��, (If city,give street address)
Name of deceased ,,. (/(y/ ,
le, married, widowed, .
Sex.�.1. -" . .,CColor. .... . . ,r divorced (write the word).... Date of Dea aZ O 19..�.../
Age 0 9 Ye s..../. d .Months...cr- .9 Days Birth ace.... /.5 0 -
Cause of Death.... g.r ,./k ,t.. . . . ,,/
Certificate was signed by . �.... .. :K;: -- M.D.
Address ,�fr�ti K c2 .:,.:7
Place of Burial (or Removal)... 1 `i�}� ... ... .. ...�
(If body is to be to orari held,fin in s ace later) `.*�;
Cemetery.. ( ' 1 Date of Burial.... ... 19
(If body is to be .emporari eld,fill in space later) 92442..ag3 f/The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to he 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
Num and on the b 's theff°f I HEREBY GRANT A PERMIT
to.
4-0 tY ,--/./-e-1,-e%g-6"kt- W4Gtego. 9/' '1...
�7%////• e the . .to hold temporar. and re") the body.
(Underbiker o person baying charge of corpse) * or erwise d1 of[state ow])
Dated... % . 4:7:: 19..,,/i/ (Signed) . . . .. ..
G Loca 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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