Milleur, Cass Form VS.6L 'NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 CERTIFIC TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. ...-
Town
/ Town �
Dist. N ‘�/ County..i .�!`�% Village . ; ,��.
#7 C t (If city,give street add ss)
Name of deceased
Single, married, widowed,
Sex� <.... .....Color..... . . ... ...or divorced (write t e word).. ... . Date o Death.. �/ 19 .
Age... ....C�...........Yea Months I.K Da s Birthplac /.GP L/ •
Cause of Death.. -. .. .. el41 .... ..
Certificate was signed by ✓.. - 0. M.D.
Address %� , -
Place of Burial (o: Removal
(If body is to be 4;:rly in ace later) ,
Cemetery .�.. ' ��e Date of Burial.. .� 19�/
(If body is to be temporarily h , fill 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 acce ted the same for registration, have recorded it in my Lo ecor with the above
stated Registered
Number don a • ther RFBY GRANT A PER ' `�! '`
,'_
( ame) (Address)
the to hold temporaril the body.
( TL ��or erson harge pse) (Inte e, ,,_ ,,.,,,,vise dispose of[state how])
Dated 19. (Signed) ... ..... :... .. .��
Loc 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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