De Marsh, Nelson 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. /%).---
Dist. No.trd 0/ County --1.47,4---4--,----re--- ViThrtge. ..AVre•g-- ,Q-,,,ge -/fZec
Name of deceased dere,47._,ec.01.,i . ,.."7•
or—EXte (If city,give street address)
ei." Single, married, widowed,
Sex 7Z. Color or divorced (write the,word) —,-Z-ri Date of De th
Age ro Year§ Mon s / ,1 Days Birthplace.
Cause of Death,.-4,.. .1
. . ... .. .
Certificate was signed by • M.D.
•
Address ,e---
Place of Burial (or Remov 1)
(If body body is to bext.kej ncety h fi n apse ater)
Cemetery Date of Burial. /
(If body is to be temporarily held,fil 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 Local Record with the above stated Registered
Number, d on the sis ree;r1-1 B GRANT A PERMIT
Name) dress)
the to hold temporarily an e body.
(Und 4.er or person having cha
Datedrgrpse) er r o t ise ,)os h
(Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su t to local
cemetery or other regulations), unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is quired.
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