Van Norden, Souse Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ita' 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 occu red after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICA3E OF
DEATH, LEGIBLY WRITTEN IN DUR E BLACK INK. Regis ered o. ,, ._..79
/ 41,
Dist. NoGO( County i}lag�e Tarova'� / •
e i// a ��r.�:c}�Lyt,.—( /J (If city, giv street address)
Name of deceased !///
�! / ���,��t Single, married, widowed, eel
Sex/ i(olor u'So or divorced (write the word) "" Date of Death. OA'G -/ 19 Age 7! Ye s.... 2 Months.... D. ... Day a l Birt lacey47`'�'
C use of Death.. - -
Certificate was sig y —4._;,,,..... . .g. .... M.D.
Address.. ... .. /—
Place of Buy ial (or :I.•val) Kth't
(If body is to be tempo eld, 1 n space Iatery
Cemetery Date of Burial V � Ay 4/:-'''
(If body is to be temporarily held,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 accepted the sam- fo re e .t�. / ,av ecorded it in my Local ec rd with the v stated Reg' ered
Number, an' on the -
�,I er:t �,t 4 7 RANT APERMIT / v�
the .... *f#4"0%,s to hold temporaril d.... , -.,...it I d ess)
.4 th ody.
( tak r or pg�on suing charge co pse) ,remove,or otheee dis of slat ho
Dated.... ...../ .. f 19.. .. (Signed).
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject o local
cemetery or other regulations), unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is requi d.
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