Bower, William Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to' 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. R�ir/�ed No..:_.1- .
Dist. NJC of County ��� Town4g.,..,_____, /J/ r
Lam(.. Village
• L / " r City (Ii city,give street address)
Name of deceased /l(/
Single, married, widowed,
Sex. Color �� or divorced (write the word) �'1�-� Date of Death..' , . ... 19 A
Age l,..i Year > Mon ays irthplace
Cause of Death — ,l
Certificate was signed e M.D.
Address w� . ..l
Place of Burial (o e oval) ,
(If body is to be tem held,fill in space later)
Cemetery Date of Burial.. ��` / - ? 19
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated 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 re 'stratio , ye d it in my Local Record with the abo tat egistered
Number, and o e basis` ;�H Y NTA PERMIT _
to
(Name) ( )
the • •. ... .. ...... .. ... to hold temporarily and the dy.
(Under erson •n char e o r se me a ve,or otherwise die+yose o to how])
6 $ p ) ✓
Dated .,4..�.19.. .�c (Signed)... (...:-
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su 3e 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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