Hubert, Christina Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Towi
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE 0
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. gistered No._. .. -
Town '
Dist. Na.L..�!�1...County.. ��f/ . Villager 9lr ..rei sip ,1 0,0..eiti
d
r it (If city, give-street address)
Name, of deceased ... . .�� .. .. .... •.
Single, married, widowed4Ati ,
•
•
Sex.f! lor..L or divorced (write the word
) Date of at r 19.Age / f Ye Mon s a Da s i ac . .>.
cause of Death.... . . . .. . . ... .. . .. •
Certificate was si ��j .. .. ;
M.1
Address.. s Cer�"� .�..
Place of Burial (or Removal) p. ., w ,.. ..
(If body Is to bet o ly ,8 ce later �o� ji--,:qe.
If body is G� �-'��K:� Date of Burial 19.t J
(If body is to be temporarily held, fill in apace later)
The Certificate of Death containing the above stated particu ars, having been presented to me, after careful exami
nation, the same appearing to be COMPLETE, CORRECT. AND SATISFACTORY AS R F' iLIRED I3Y I.ANV
I have accepted the same for registration, have recorded it in my Local Record with a above stated Registere<
Number, �>�d on the b' s' .thereof I OF Y A PERMIT 2
to area
the . .. to hold tempor, i y nd the body
(Undp r r on having ebarge//off� orpse) ova,or ,ose of how))
Dated CT ,,..._ 19..Y (Signed)...
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Sta (subject to loca
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