Demers, Baby boy Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 E4Of
DEATH, LEGIBLY WRITTEN IN DURABLE B CK INK. Registers No........_.__.. .,c
Dist. No1,,a •
...�.u...1..County •
. .. . .. .. . '
Or (If City, give street addres
Name of deceased
le, arried, widow ,
S . ... O olor ivorced (write the ord). Date of 5; z:k.).. / 95C 1
Age Year C3 Months d Da s Birthplace.... '^
- _
Cause of Death . . ....�,h..�Q �, . . ,•. ,..• .
Certificate was si M.D.
Address 2--• • .
Place of Burial (or Removal). ... . .. ... ... ..
(If body is to��ee+��+ mporarily held, 11 n space la er i
C body s o be to porar Date of Burial... ... .. /<PA 1 .. ...
(If body is to be temporar' held,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 acce. . the same for registratio have recorded it in my Local Record with the above stated Registered
Num. r, ;J on the ba is tlre,of. H EBY PERMI
to ,
the , • ,.. • .. to hold temporaril (Ad .. . . he y.
(Milt ker or person havi barge f corpse) n , r t e to ow
Dated /... .! 19. • (Signed).
Local Re tram
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subj t to 1 cal
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is re iced.
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