Durrin, Anthony Form VS. 6I. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 CERTI^FI . OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.....
OK
/ g f/A
Dist. Nq)..b 6 County -T=iHae.
o City
(If city, give street address)
Name of deceased
/ Single, married, wido ed,
Sex. .. ..ColorE,,(/ or divorced (write the wor Date of v.. y_e�� 19. ..
Age L_ Years -.--::.Months Day Birthplace.. J�f.�re. ^7s-�
Cause of Death
Certificate was signed by 11.D.
Address .... �.
Place of Burial (or R a1) sa "..... i
(If body is to be temporar' eld,fill i space later)
Cemetery Date Burial A G 19..K
(If body is to be tempor ly held, tit! '.n space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the s.me appearing to se COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have aced the same f. r stralion, av� recorded it in my L ord with the y stated Registered
Numbe ,: d on the b..i - .`f I HE' DP: RANT A PERMI
to �i
r� dress)
the 9 ... % '� %/!..rflw to hold temporarily a d he body.
.. . .. . .... . .
(Unde faker or i erson ha 'ng charg• . corpse) remove,or otteise di e of [state I)
Dated..... 40'. 01 19.. .. (Signed)
Local Registrar
This Perm is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ject 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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