Prouty, Carl Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
. 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..._..._.._._._._._
Dist. Nd '5. .S.Cou . .. Ville
t `�
�, � Q/J �A)p it (If city, give street address)
'Name of deceased Ci.1.Y..cC....... ... .... .... ..."'..... .. .
yy} Single, married, wid ed, •
Sex 1 '...Color.... . or divorced (write he word)rii .. . Date o ath.... 19.. . j
Age £...Yea Monts 7 Days Birthplace.. . 4..41 ....•
Cause of Death........ .
Certificate was signed 11 , 771, .a... M.D.
Address .,�:::ti1..•tJ...t...
Place of Burial or Removal). .. r .. , .A.A.•,:t.f� _e.,,4.. ). 4
. .... .. . . .... ....
(If body is to be t m orsrily held,rrl)Ln space later) r
Ce%etery......�j....,C c.a!„r....1(.1. Date of Burial... I 0 19.'?
(If body is to be temporarily held,1111 in space later)
The Certificate of Death containing the above stated particulars, having been presen ed 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
Num r, and en baWhf I I�EBY NT A PERMIT
to... S.IC' ' •Alz<--K--“(rie /7 •y,
(Name) (Address)
the to hold tempo ari and ✓ the body.
er eNor person h ving charge orpse) (Inter,remove, therwise s of[state howl)
Dated.. 19..) (Signed). . .
Local Registrar
This P rmit is sufficient for the Removal (and Interment or Cremation) of bod to any part of the tate (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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