Kuntz, Mary Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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. Registered o../Z_/.
Dist. Now County CO.C!?-t^!'`4r--• -Village �.1 plX. f
14,
or CO (If city,give street address)
Name of deceased
yy�� S' le, married, wi owed, .
Sexle►. .Color VI ..or divorced (write the word) Date of Dfieath.. G 19.1.' a.
Age 2/ Years ! Months �— Days Birth lace "\Y t------44 -)7 y
Cause of Death . . . % t,,'.,rit
Certificate was signed b �i f
_. M.D.
_
Address 7 .-r� '�-�'"�... �c� l' 3� f
Place of Burial (or Removal) - -. 2j
(If body is to be temporaril h Id,fill in space later) /Cemetery... , Date of Burial L/ �P 19.I1E
(If body is to be temporarily eld,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 registration, have recorded it in my Lo 1 Record wi h the above stated Registered
Nu er, d on th sis thereof I •E: G;ANT A PERMIT
to.. . . . . ,� t .
e) /?/ri/ ddreas)
the too h 1 6 temporarily �•' the dy.
(U.•e :ker,,r person having charge of orpse) n , rote isno s to how
Dated # .' a2 9, 19.. (e. (Signed)....
f Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subje 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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