Lee, Aurellia Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
vr 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 CERTIFIICAtE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. 9
GZ d/ Town �� .. rP-e .
Dist. No County., r .. .. Village
Or City (If city,give street address)
Name of deceased............: .. . . ..., .
Single, married, widowed, , ,1
Sex Color '....or divorced (write the word).1"--/ �i.Date of Death % - 191 6
Age Years....„... AA-.........Months... Days Birthplac
Cause of Death 444---4-7-7".•>9.1
D
Certificate was signed by -9-J). . .. . . .-41— M.D.
Address ..... . ..)'I -
Place of Burial or Removal) 7
(If body is to be te..;•,arily held 11 in ace later).
Cemetery IDate of rial.. ...?3 19. .i..
(If body is to .e temporarily hel • 11 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 Local cord with the above stated Registered
Number nd on the bates they f I HEREBY GRANT A PERMIT
) Address)
the to hold tempor ri - d.. .X e dy.
rtaker or erso havingchar a cor se �_ ••( P 8 P ) •, . o er dis [a
r
Dated ... ..,�,�..19.. ... (Signed). ... .. ...
Local Regis ar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State subj ct to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is req fired.
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