Esmond, Bessie •
Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tT 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. Town Registered No.
Village
Dist. NOS . ..County ( a--1 1 of-Eity - b' '-Z-c
• (If city, give street ages)
Name of deceased �„ s Veteran '
Single, married, widowed, • (If v ersn, s' name of Was)
Sex *2 .Color 1f or divorced (wri e word).:�� �... Date Death...���'
�f J .
Age......:a:... 4 Years /0 Mon .15.. Days t �/ B�irthplace 4sK ... . !�
Cause of Death 4-( Anr A .ar,��.a. ,
-
Certificate was signed by „ M.D.
Address
Place of Burial (oz.Removal) 1.. ' l ., .
(If body is to be tempsafily held,fil pace laa )
Cemetery 9 --- : ,(� ,r�1,t .Date of Burial 19.. ..
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above state 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, and on the bEyr ereof I HER G �NT A PERMIT -.ca.e4 �'L'U
to nc .....
•
£ ) Address)
the -'a ;.n ed :� to hold temporarily and the body.
(U�a ertaker perso61�aving charge of c6rbee) Inter,repiov or o e se dish f[state how])
Dated Sr : 19.4 ;... (Signed) -_ �.. ,/
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
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