Barney, Clover Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sir 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 DURABLE BLACK INK. Registered No.
TeW/I �� � � � p�
Dist. No��r Q�...County.. ..L , Vie./G../�0':4:44..ri�.ir' f fieef. 7 ... ..7
Oi Clty (If city, give street address)
Name of deceased
Sex.��;, Single, married, widowed, �L '
'r the..-Color G !o:- divorced (write the word). , . . Date of Death: r 19..X�
Age `-J' Years 4 Months id Days Birth lace
Cause of Death . .. ,ratfrat..H
Certificate was si ned by .. M.D.
Address '4/4(49
. ..L.. . 1
7!
Place of Burial (or Removal)...?ete.
(If body is to bet po r ly he ,fill in space later) • � ' _ , �/
Cemetery.. Date o Burial �J C.I 19..1":�..... . . . . .. .. ..
(If body is to be tempura y 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
Nu r, and on a basis thereof I ,HEREBY GRANT A PERMIT '�``��,� A'
to... . .. .. ..Y... . '��/.l / t.✓...'it r.,�d , j�J
( (A ss) �
the to hold temporarily an .d;,G�,. ,. th body.
( ertaker or erson having charge of corpse) temporarily
ore,or otherwitisno state how]
Dated -� j& 19...E...4 (Signed) • cal G... ...
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part.of the State (su ' ct 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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