O'Brien, Charles 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 01
DEATH, LEGIBLY WRITTEN IN DU LE BLACK INK.
-- '�Regiatered N�oQ..._...f_.,?__.
Dist. No v61./ County TVillage.f'G L "'�""' `/''e '6"t-'.sr
y� , O ltY (IP city, glue street a teas)
Name of deceased �. • ..... .. .. ..
,,�i Single, married, widowed,
Sex"" -44 .Colo f "�`'' or divorced (writ th2 word) : — Date of th.. ..... . ( 19.
Age40 Years ,Months 4 f" Days Birthplace , Gf9""
Cause. of Death 'l/
Certificate was signe ,/.�• .. .. � M.D
Address .f � ../" �.
Place of Burial (or R val) 7 •'
(If body is to be tempora Id,tilI in space•later) ,�
Cemetery ate of Butial.... //v 19.l--'
(If body is to be temporarily held,till in space later)
The Certificate of Death containing the above stated particulars, having been presented o me, after careful exami-
nation, the sa appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accep the same for ,- "dratio:, ha -e recorded it in my Local ord with the above stated Registered
Number, • . a bas' a f I RANT A PERMI
to • •►
the N.... . to hold temporarily
ann{,, sa e body.
(L nde er or person h}y f l ng'charge f orpae) eG(" I e or other diva [st e )
Dated . . ,1�/ 19. � (Signed)
Local Registrar
This Permit is s ficient for the Removal (and Interment or Cremation) of a body to any part of the State (su )ect to local
cemetery or other re lations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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