Kelley, Celia Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t' 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 CERTIFICA EE of..-
DEATH, LEGIBLY WRITTEN IN DURABLE CK INK. Town Registered No. ' '1 Sr
400. 0...„
Dist,No...4. ..e/County or CityVillage ��....
(If city,give street address)
Name of deceased 'al Veteran
�_
ngle, married, widow , veteran, give name of War)
S w�•... .. . .. c i r divorced (writl,the wo ...Date of De . . f 19
Av- 24".. ears Months. �� ays Birthplace ,...��r
(ruse of Death. ... • .• ... »�
... . . . ... ....
Certificate was signed by i Vie . M.D.
Address
Place of Burial (or Rem al). . - %—:',e,.
(If body Is to b t mporar held,till 1 ace later)
Cemete12y /.�. Date of Burial , ..4...19. �0
(If body to be temporarily d,fill in apace later)
The,Certificate of Death containing the above stated particulars, having been pr nted to m , after careful exami-
nation, the same appearin: to se COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accept the same •r rein ration, have recorded it in my Local Record with the above stated Regi
Number, nl ba s ther. I!1� �1 I3')GRANT A PERMIT
to ,,� GAT/
the ,ih 'arms)
-.AO:. .. .•to hold temporaril and. (Add the er.ts
(U• r or verso. having charge of corpse) nt o t r one h I)
Dated %19y" (Signed) .. .. ... .. ... .
/ Local Registrar
This ermit is suffi -"t for the Removal (and Interment or Cremation) of a body to any part of the State (subject t local
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