Washburn, Cora Form VS.6L NEW FORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re. 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
3.
Dist. No 6 County Town
Village
Village
�/ Or City (If city,give t address)
Name of deceased ,�,��-` �,4z
X,...7
� 'ngle, married, widowed,
Se olor. �� divorced (write the wo Date of e -- . 19. '...
Agj, Years ,f M nths./7 Days Birthplac�f <..
Cause of Death. `'� �/
Certificate was sib b-. .f, ,.lr ��
M.D.
Address.... . ..
Place of Burial (or Removal) ,1, ,,�11, , ,.. _ , ,1-4
(If body is to be tem rily , fill 1 sp a later)
Cemetery. �% /�� .:� � ...,,, ,�:,� J Date of Burial 19
(If body is to be temporarily eld,El 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
N r, and o pasis he eo E BY GRANT A PERMI
to ..
..(•••. Q (Address)
4.515.0 Z to hold temporar. and. the body.
�`� (Und taker peon having charge of corpse) to ov otherwise dispose of [state how])
rated . . ,s 19.��. 2 (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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