Middleton, James 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.........._._....___
c.
nn � ,,r Town
Dist. No County.'lrS,d. 4 rHagq ..
(If city,give street address)
Name of deceased. . ..... .. .
gle, married, widv*,
Sex ,,.Colo .r ddorced.(write the word).. 4. Date of eathi..0_,C,,,f.....1 19..If..4.
Age........ Ye rs onth .... Day Birthplace..
lkie
Cause of Death.... .. . . . ... . ..-Q�'. .. . ..
.. .
Certificate was signed by ., .1.. M.D.
Address ,. l
Place of Burial (or Removal)..... ... t.,M:6.1 ..... ..tr U.) 0../.0-G.kkwe.
(If body is to be tempoly held,fill in c later) `J
Cemetery �..,—:.r.,.- Date of Burial...gTrit.1, 1.1 19 --
(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 REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
N er, and on the basis reof HER GRANT. rAER�M T )7itriA40,1 • /,,
..4,13,— ...„,,.
la
the to hold temporari y d , '� the body.
(U�g rta� or pe on having charg f, orpse) ( ter move a di j)
Dated k.�L.. .L.. 19.k (Signed)
ocal Regis rar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b..y to any part of the State (subject to local
remetery or other revulations).unless removal is by common carrier. in which case a ransit Permit (VS No. 62) is required.
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