Blackburn, Nellie Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
82r 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. .C///..��County.. .. . Town Village 2rei .. y�/ / or City (If city,give street ddress)
Name of deceased 2.-. 6 t:.'�� .....1 f-` „
Single, married, widowed,
Sex .... ....Color V/ or divorced (write the. word).... ..... Date of Death 22,- 2./ 19. .Z
Age .85. y`..Years / ' Months. ....,r>�.,! Days Birthplac
Cause of Death ,,,,,
Certificate was signed by ..... M.D.
Address
Place of VI (or Removal). ,,
2.0 l
(If body 1smporarily held,fl space later)
Cemetery . .. LZ-ss..t2... Date of Burial 2 ..g-./ 19 2.
(If body is to be temperer' eid,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 same for registration, have recorded it in my Local Record with the above stated Registered
Number,�and on
LL on basis th �eof I H R Y GRANT A PE
RMITy�/i• � f� ,A
7 (Name) ddress) ,///
the 244 f .Z to hold temporarily a d the body.
(Undertaker or person having cha ge f corpse) (Inter, move, therwise dig se of[state how])
Dated....,llG. l.,..,,42... 19.,lpX. (Signed) . .. . : at...4.c. .r
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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