Brilling, Anna Form VS.6L NEW YORK STATE -DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Car 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 CERTIFICATA OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. 6' -/
Town
Dist. No SG 4/ County....t4/.ez....I:lt�.....�,w Vitrage A14-2-c-r-7 •--
or City (If city,give street address)
Name of deceased - ...-- ,
Single, married, widowed,
S for r divorced (write the word)... .4....:4 p..Date of Death--i 19. 4..
Age I/5 Ye rs .? Months /G Days Birthpla e....��..f.., •
. / `y�C
Cause of Death... .. ... A.... .
Certificate was signed by M.D.
Address •
Place of Burial (or Removal)
(If body is to be tpmpoiarily held, fill in space lat ) -..
Cemetery .. . . A_ Date of urial fg .19 l6
(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, aft-6 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, a d the basis,thze I EREBY GRANT A PERMIT ,� _ Q�.
to Za�i mot/. ,..,-• C�-w��' `c.�""/ `-if 'he
the to hold tembody.
(17 aker r person havinarof corpse) i/x
Dated r19 . ... (Signed) . .. . ... .. .......'.... ..
Local Registrar
This Permit is suffici for the Removal (and Interment or Cremation) of a body to any part of the State ( bject 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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