Bovee, Thelma Form V .fil. NEW YORK STATE DEPART T OF HEALTH
OFFICIAL BURIAL (OR RE lV'AL) PERMIT
This Permit can be signed only by the Local Registrar (Deputy ors registrar) of the Primary Registration District (Town
Village, or City) in which the death occurred after the FILING and accep an.'. of a CORRECT ' ` ► OMPLETE CERTIFICATE Of
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No
Town /
�^
Dist. No Iv Counts- GG�'�' �� FFillag: C 'r e , • ,,
ao--- - /4„.a..4..c..er I ity (If city, give street addre
Name of deceased
Single, married, widowed,
Sex Color or divorced (write the word) - Date of Death. 6.6. 19.94
Age .a�. Years Months.. Teli. Da�\ t rthplace
Cause of eath...���Q,4,441• t.[ •• \r
Certificate was signed b5- .., M.D
Address
a 41(11/
Place of Furial (or Re oval) i ♦ _r(If body Is to/y�►tempnr rily ,liil in sree�
,,
Cemetery X hate of Burial 19
(If body Is to be temporarily held. till in apace later)
The Certificate of Death containing the above stated / ,ulars, 1 ving been presented o me, after careful exami-
nation, the same appearing to be COMPLETE, CO 'R�i 1 T, AN 7 SATISFACTORY AS REQUIRED BY LAW.
I have a epted the same for registration, have reco teal! it in m, L.cal Record with the above stated Registered
Numbe and on the asis- I ` : R � PER I,
Tom'- '
( \ (Address)
the .. ho emporaril • .. the body.
(ti dertaker or person having charge of corpse) / I e o or ter isny; toe how
Dated /6 19... 6 - Sign d
Local Registrar
This Perini 'is sufficient for the Removal (and Intern-f., or Cremation) of a body to any part of the State (sub' ct 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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