Chadwick, Hortense Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ta. 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 CERTIFIC`L I ,OF
DEATH, LEGIBLY WRITTEN IN RABLE BLACK INK. Registered No. C3
,.- Town
Dist. No.4sw v County ZT illage
/ ity, give street address)
Name of deceased /V
Single, married, widowed, •
Sex Col r divorced (write the word) Date f ath.. /`" 19'1�
Age P� Years nths... 02 / ... D»ays Birthplace. '
Cause of Death ... ... . .... /
1'-G
Certificate was signed by ,.j ...... ..., M.D.
Address r / f
Place of Burial (or Remov 1) �/(If body 1 emp 'arily�sa fill in space later)Cemete / Date o,y,
rial /6 19 fe2—
(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 RE UIRED BY LAW.
I have accepted the same for registration, have recorded it in my Local Reco w' h the a stated Registered
Numb on the basis thereof REBY GRANT A PERMIT
to... >7 ,
(Na ) • (Add )
the to hold temporarily d th od•r
(I' d rt er or erson havlpg char a of corpse) ( ,remove otherwise dispose of[state how])
Dated l `' 19`?----- ' (Signed)
Local Registrar
is 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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