Selleck, Thelda Form VS.6L 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
b Town
Dist. No/ `5 '-' County
. Village... .�(::( f cI ty, give street address)
Name of deceased „�„, :Y;,..e
Single, married, widowed, dJ/�
Se , .. . . Colo / or divorced (write the word .ems- :.Date of th. F A. 1942
Age > Year Months `� ,....Da s Birthplace... .
Cause of Death }
Certificate was signed by. M.D.
Address .1.. .A.�l 2�.- 4.�~
.i
Place of Burial (or Removal) " J -_
(If body is to be temporarily held,fill in space later?
Cemetery :N,,,kl:C1.Qs..L.'...' i Date of Burial.`` .. e,s....��,�.. 19r 2
(If body is to be temporarily 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
N , per, and G�;the basis e f I HEREBY GRANT A PERMIT�,y y,r D�
t• " • • cii ..1...-41.(.' . .. /��/.Y- .. .).)14..ti.1G./..�zV.L.4A, ,) . .. GIrS.t1 ..'f U,GIt.o�hi-
(Nano C ddreas)
the. to hold temporaril and the body.
( dertaker or p rson having charge ot,corpse) (Inter, ,or t rwlse dish e o [ to h j) __
Dated.... . . �' 19..1,.,;,, (Signed) .. -el- vl� - , ....
Y
Local Regis ar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pa of the State (subject 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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