Chadwick, Warren T
orm Vd.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tV 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. fa
�---�^ Town
Dist. No, 6.C.11 Count l...l ... Village
r City (If city,give street address)
Name of deceased 2C4 -C-e/
�+ ' gle, married, widowed, ` �-
Sex G!I�,LRX,�olor . -. 'divorced (write the word) �1.. .Date of eath 19 .2
Age $.0 ears Months / Days irthplace. .
Cause of Death ��lrt,�Ik4(1. .. lt' !. ... .
Certificate was signed by • ' M
Address •••••
Place of Burial (or Removal).. .. .. . .. ... .. ...... .... =
(If body is te,l�q,tCuu�or eld fill in apace later)
Cemetery 'f�/I/IH7� Date o Burial 19•4•..2
(If body is to be temporarily held,Jill 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
Nu r, and on the b sis a eof I HEREBY GRANT A PERMIT �n
rl
ddress)
the to hold temporar' nd th body.
rtaker or pe h -i charge of corpse) ( nter..ro r,of er dispose o [state howl)
Dated..:. .. 19...4Fp--- (Signed) �. ..
//y� ocal Registrar
This Permit is sufficient for the Removal (and Interment or Crenifition) f a ody any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Tr ' it Permit (VS No. 62) is required.
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