Cox, Baby girl orm VS. 6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itr 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 CERT OF
DEATH, LEGIBLY WRITTEN IN DUR F. BLACK INK. /..fr„...;:e4egistered No.
TarTr
Dist. N County.... • V. e
Or (If city, give street add ss)
Name of dece ed
/�� Single, ' , widevr6d, ''
Seal Color or div d (write the word) .: Date of ad . 19.5/`V
Age Years . onths Days30 • Birthplace.
Cause of Death
Certificate was signed by G714 M.D.
Address a4....� 4( ' ?•
Place of Burial (or Removal)..
(If body is to be temp held, fill in spa er
Cemetery ..� h l... . ... Date of Burial . ......... ... . //V 19 t`
(If body is to be tempo ari y held,fill in a e la .
The Certificate of Death contai g e above stated parts ulars, having been presented to me, after careful exami-
nation, the same appearing to e OMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accept e same for re •strat• , have r red it in my Local Recc dd''th the ahoy s ted Registered
Number, an n basis th EBY A PERM pq� GGe
a Addre
the to hold temporarily and. • .the body_
(U r on>11 charge o corpse) n ove,or other se di wl)
Dated / 19.�"..te (Signed) .. ... .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( ubject 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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