Varney, Linda Form VS.GI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CERTIFI�Cf� OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No..(47..'T"
Dist. No . OI County (.4ef.eie0 C9a-led"
.... ../...11... .. ... .... . ... ./ tiLi}lager.... .....
aF City / I (If city, give street address)
Name of deceased /V/
Single, married, widowed, •
Se . . . . lor. . ... . or divorced (w ite the word).... .. .. .. Date o ath.. . . ....19,
Agg ► .02 M Day a- Birthplace..
Cause of Death
Certificate was signed by M.D.
Address
Place of Buria or Removal)
... . .. ... .. .
(If body is to bet orar he il I pace later)
Cemetery....:..... Date o urial.... . . . 19.413
(If body Is to be temporarily he! 11 In space later)
The Certificate of Death containing the above stated particulars, having been pr tinted to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have acc ted the same for registr tion., have recorded it in my 1L I Record with the above stated Registered
Number, don the b is ereof EREBY.GRANT A PERMI
to i : ege . .
( ddress)
the to hold temporal' nd the body.
(Uncle r o person having charge oE rpse) ter,re ove,p�oherw a se of [sta how])
Dated -. 11 19. (Signed) /�Al.r<
Local Registrar
This Pe mit is sufficient for the Removal (and Interment or Cre i n f a o y o any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in whi case a nsit Permit (VS No. 62) is required.
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