Demarest, Bertha Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
12T 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.
n . . . . . ../ es f
Dist. No.o�.Q7 County +� .. Village
�� __ /fJ 91`CltyL. (If city, give street address)
N ime of deceased h�: .��� ... .. .
Single, married, widowed, 1 •
Sex Color. - or divorced (wr e wirrr1). .�1. Date of D ath. . gq: 19.,+.3
Age....,�..A 9 Y rs.... .., — Months 7'i Days ifthplace. .... .. . 11Lc
Cause of Death. , '
Certificate was signed by - 4
.27 � M.D.
Address t'
Place of Burial (o oval) i } U
(If body is to be tern y held,fill in Ater),"
Cemetery ... �. Bur
ial - -C? 19. 3
(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
Number on the b sis jjeereof ,• E' Y ANT A PERMIT
me efIr"le'.. � e-s?,,.... /'.
the :.e to hold temporarily nd he body.
(Una• ker or .erso a$charge se) (I re ove,or oth 'se dis of[state ])
Dated. ... 19...7 i (Sighed).... . ..
` ocal Registrar
This eermit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su ect 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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