Bennett, Orley Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tow.:,
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. Re tered No.
/� Town
Dist. Nd.C ../..Count ..
y.. . ... ... .... . �ri1'ag'e ..
tar (If city, give street
i—
Name of deceased �_ Y„ „
/J�2(���Sm le, ` cried, widowed,
Se . .�ii ..Colorl. C� yor divorced (write lt/he word) Date of D h !/Y 3 19. p�
Age Ca..Q Years g .� Months Ii Days Birthplace. ,►� ;;
Cause of Death /,�A .... _,
Certificate was signed by (,.... ,,. 7 6- . M.D.
Address
Place of Burial (or Removal) ....„::a/ . �� � e
(If body is to be temporarily held,fill 1 p �later) `
Cemetery ^� U/ Date of Burial:i ! ay 6 19.. -
(If body is to be temporarily held,fill in space later) ((
The Certificate of Death containing the above stated particulars, having been presente I to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have, cepted the for regist 'on, have recorded it in my Local Record with the above stated Registered
Numbe , and on the is thereof _ Y GRANT A PERMIT
to ��� - , ihz ca�2iL21-1
ire' " fN $9_�J (Address)
the r_. - ;�� c71(,X to hold temporarily a d the body.
(Unde er or person tlQving charge of corpse) (Inter,re ove,o•o rwi a wee of( to how])
Dated........ ... ... 6 (p 19... ... (Signed)..
Local Registrar
This Permit is/4ufficient for the Removal (and Interment or re tion) o a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, which.case a Transit Permit (VS No. 62) is required.
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