Sansouci, Ellen Form VS. 6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can be signed only by the Loial 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
9
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. D 6
Dist. No R! County. I �7
y i>�rlt�ge Gfr!!ry .�1 .
• c City (If city,give street address)
Name of deceased .
60101
p'L Single, married, widowed, --A( ���
Sex .Color or divorced (write the word) // Date of Death 44e/.., 4 ►'� 19..
Age 74 Years Ill" Months 4 414 Days Birthplace. ...d/tre 4 ' 22.t:,,
Cause of Death • ,,hh
Certificate was signed b , 'j, �� (aa t 'l,..A0 ,. M.D.
Address
Place`of Bui'al (or Removal) ete,sel-r&-•
(If bodyis to b m or 1 el fill in space lat r)P ��//
Cemetery. ...
. . . . ... ... .. . ate of Burial... .rf l... 4.1 19..T$
(If body is to be tempora y held,fill in space later)
The Certificate of Death containing the above stated rticulars, 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 R d with the above stated Registered
Nnumber, d on the bads tbr E� GRANT A PERM �- A � ��
,�� a ) (Address) %fir-�
the to hold tempora ' nd 'y the body.
(41erl,alter '
Dated. �......4.ec:..1. ,19.... ... (Signed) .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cr i o a dy to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in ich cas Transit Permit (VS No. 62) is required.
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