Fitzpatrick, Helen Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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.•? ll'Z,..
Villagezp
Dist. NoS.%di County C-4V-48-1.etni,................ or City --- --70--.--- _-c.#.4.„4 ,,,
(If city, give street add peas)
Name of deceased (7.41--t-,-L.) (2
, ".,c- -)4.,,, .e._.e. c..al Veteran
i A Single, married, widowed," • (If veteran, give name of Was)
Sex.9-greKA-4,81ort..-A-' or divorced (write the word) Date of De th /4 .19
Age G° Years 4 .Months AZ .-- .Days Birthplace. " 4-72
Cause of Death . .,.......c.........1
Certificate was signed by M.D.
Address - 1 -4°17:.11.."?7. ' •
Place of Burial (or Removal) e.4.--,-.1--1-.-,e7kA:Z.„.4-4.9-.04-...-24.4.-7, 71. -r7i,
(If body Is to be tworarily helc1,76=ce lagp)
Cemetery .1----c—K f.) " Date of i3urial /5'
-**, 19/6
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above state particulars, having been presented me, after careful exami-
nation, the same appearing to be COMPLETE, CORRELL AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Lo I Record with the above stated Registered
GRANT A PERMIT
Numberlg,,,ot.n,e,..t.erlm Vi.sle I REB
to
(N (liddre )
the ....... ... . .. .. ... -..to hold temporarily and the body.
(tin maker or pens"having charge,yf corpse) (I rem v r oawise of[s how])
Dated Y 19.f4. : (Signed)
6 b , Local Regi
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part o the State (subject to local
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