Bates, Orlie 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 (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. istered No.
.{ / , ) Town
Dist. No., -4). .7County. .�/ gee• ••••
, �}/ Elt (If city, give street addr
Name of deceased
1 Ingle, married, widowed,
Sexc t/ t Color_1(// r divorced (writ the word) � -e1 Date of Death. ... ... .... ././...19..�/2-
Age 3 ...Years.... .11 Months . Da s Birthplac 7— .444 :
Cause of Death
/cy
Certificate was signed by f.... .•. L"� M.D.
Address !�.'1 .... .. .-. ..• `� -••.
.... .... . .. .. ...
Place of Burial (or Removal) .. I
(If body is to be temporarily held,fill in space later)
Cemetery ,. I- ,t.r Date of B rial.. . . . /V 19••
(It body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been esented to me, after careful exami-
nation the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have .ccepted the s e for registration, have recorded it in my Local cor with the a ove stated Registered
Numb , and on the as bireo liGRANT A PERMIT ✓�7
to.. ..
( e) Ad ess)
the.... to hold temporaril nd the body.
'ndertaker or person IIa ng charge of orpse) (Int r e, oth rwise dis ose of [state howj)
Dated. .7... 19.. a�,, (Signed) . . "I' Local Registrar
is Permit is sufficient for the Removal (and Interment or r ation) a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier whit case a Transit Permit (VS No. 62) is required.
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