Blanchard, Myron 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,
Villa.e, 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.
Town
Dist. No '16.6./County lags
y (If ,give st t address)
Name of deceased •
Single, rried, widowed, //,-
Sex.. .,...Color ` or divorced (write the word).(./.LGL ate of Death'.. , (8' 19. 0
Age ,� Years.... ... etlthst Q Mays Birthplace
Cause of Beath /
Certificate was signed by } M.D.
Address ] l � . g... ... /,
Place of Bui'al (or Removal) :/ AA+ , ...... ,,, e(/" y,
(Ii body is to be temporarily held,fill 1n space later) q_..1! �_.,Y...�. / �b 19 ��
Cemetery.. .... ._.. 4.� k.E Date of Burial...f,Y "/.�
(It 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 registr tion, have recorded it in my Loca Re ord with the above stated Registered
Numbs d ((�� •
to. ,,o�the as t eof R GR T A PERMIT �p,,� 0�,�'
.}.m� ddress)
the eY.1.�/� W v .to hold temporarily and S the body.
T r kerr or perso baying,charge o corps Inter r o e,or otherwise dispose of[state how])
��
Dated..��.. !EJ..�,p�;.,.�.�...19..��., (Signed) p" t... t
Local Registrar
This Permit is sufficient for the Removal (and Interment or CremeI o body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in h c e a Transit Permit (VS No. 62) is required.
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