Moquin, Delvina Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
L 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 CERTIELICME OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No..f,.... •Vc:FL—
Dist. NiS56-47./County 9,7/-..ear-44-4-7(-•••" TQ''-‘44';8.?yea.c,‘,a_regoefeac772.4. -,)
or City ' (If city,give street address)
Name of deceased der:2-4414A-Ge•Xc:Cei
- ingle, married, widowed,
Sex-.. .Yore&olor. . .. .. r divorced (write the word).9"...41;1160441-1a.Date of Death • /01 9.Y.-::
Age N .--ti--- Years. .,.../. onths. 9474:2. Da irthplac ...e. .
Cause of Deathe . . . . . /(7 .• •
Certificate was signed b • • M.D.
Place of Burial (or :emova .. .... ... .. .... .. . . . ..
(If body is to be) o AO:iv•Id,/11 in space later) . 2
Cemete . .A..lir : 41! .. .1... 1 1 Date of Bu 1
(If body is to be tempo :Or held,fill in space later)
The Certificate of '0 eath containing the above stated part' lars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORR T, 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
Numbe and on b is th f I HEREBY GRANT A PERMIT
• . a4/ .
2( ....
. to hold temporarily so 4
and h e dispos [state ICti4ebody.
CU rtaker or person having charge of compse) ter remove,oet bow])
Dated ,24,9 19. ,„5/5l (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the te (subject to local
cemetery or other regulations), unless removal is by common carrier,in which case a Transit Permit (VS No. 2) is required.
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