Fish, Lawrence 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 CERTIFICATE.OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.......~�.;..`,
Dist. j\o..v a Village ,.i.A..County or City
r.If city, give street address)
Name of deceased — 4 ' Veteran '-
(If v an ive name of War)Single, married, widowed, ��� a., �. ,
Sex Color or divorced (write the word) -.wr Date of Death ' A `- 19.'
Age Years Months...... %;/.....,,,Days Birthplace N Cause of Death
Certificate was signed by -.ja .,.. ; i�l iydd M.D.
Address '
,, sue.. h....°
Place of Burial (or Removal) J i�„Nwg- - •�...,Ar'' Y
(If body is to be to orartl held,fill in space la ) r
Cemetery.. °'.mac .,.... F e of Burial did%� 7" 4 19...'/
(If body le to be temporar y held, fill in space later) �y/e*
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 Local Record with the above stated Registered
Number, the basi,,fe I HER Y GRANT A PERMIT
(Name) n .y�dress)
the to hold temporarily and �f" the body.
( 34,erSpker or person having charge corpse) (Inter,remove,or otherwise dl e of[state bow])
Dated.. 'x- -- 19..2 s I,� (Signed). `` ' a re...r::—
e al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of y to any part of the State (subject 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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