Fish, Charles Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
filr 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,. OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No `�f!
/ Town /d-16 5^ Q /_Dist. No.. G f County..... VillageJ �-!�
(If City,give street address)
Name of deceased ... .. ....� _...hfQ.,�
Single, married, widowed, �I,
Se . .'ola: - • r divorced (write the word).....!(,...Date of eath. • /� 19..T�..
Age p� I a' .. . Ion s Q Days _ - ,,n Birthplace. /.
Cause of�Death.(�:�tc.l�t-.. C.-64,A. Birthplace.
.. .. .... . . . . . .... . .
-
Certificate was signed by. �,. lYl.11.
Address /.,
Place of Burial (or Removal) ..
(If body Is to b mpor fly e d fill in space r) p ,!
Cemetery. ` 2� P Dat of Burial.. ,,,.Q�/P 19..To.2
(If body Is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, h ing 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 the basis the eo� L-H _B ANT A PERMIT /.[ 1r//
( Ad
the .. �.� to hold temporar• and the body.
3erta r or person ha charge o orpee) e ,r move, :r of slat how
Dated..7 19.. (Signed)
ocal Registrar
This Permit is su ent for the Removal (and Interment or Crams ) a body any part of the State (subject to local
cemetery or other regulations).unless removal is by common carrier. in which case a T nsit Permit (VS No. 62) is required.
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