Sampson, Shirley arm 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 CERTpcjorE OF
DEATH, LEGIBLY WRITTEN IN DUR BLACK INK. _ Registered No
Town-
Dist. NS(6P l...County... .. . ... .3rti�la:,...4 /44....7*.:::::e:4„,,
)lio—
or Ci ( eet address)
Name of decea ed
/�� Single, t13a ie d, •
Se)/ olot, or diva-fee l (writ the wor Date of t f 19 2-'
Age . - Years Months... C Da s it place.Cause of Death V ... .. . �............
Certificate was signed b ... .. M.D.
Address
Place of Burial (or 'emoval)... .dIk1;[P.' 1....or ~
(If body Is to be temp.may..,, he1 1 ep later) Q l/
Cemetery ..if* Date of Burial //, 19. 1Z
(If body Is to be temporarily held, In space later)
The Certificate of Death ntaining the above stated particu ars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accept the same for re:.. ation, ha e recorded it in my Local Record with the above stated Registered
Number, on the basi - I HER NT A PERMI
to. i a ��
.me i /," (Address)
the . to hold temporarily and. ... .... .. e body.
!taker or erson charg a fro. se) r, otherv, 'snos e )
,,pp P
Date 19.7" (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sub ct 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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