Beaulac, Hermina Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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�t OF
v
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK.INK. • rr egistered No. ►.117
Va146,
Dist. No..SG V/County..Zu . . or City dy%
(If city, give address)
Name of deceased.... • —�4.�+t.Qi4 Veteran
�
GG77�Single, married, widowed, /_I (If veteran, give name of War) /
Sex ..R!1.1 or.G�.. . ... r divorced (write the word)...GU ate of e 19'�`
Age 74,, Y s Month .....2x`� Days . . Birthplace �Devi"...
Cause of Death , .
Certificate was sit' -. .y..t '� 00W M.D.
Address.... ....4 • -y
se
Place of Burial (or Removal)._ • .. •r .. . .
(If body le to be tin,()rarity 1 fit In ace later) / f/
Cemetery • Date of Burt ....l e a?.5 19T.(o.
(If body is to b,temporarily held 1 in space later)
Thu Certificate of Death ntaining 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 ted the same for egistration, have recorded it in my Lo Record with the above stated Registered
Number on the basis t r f EREBY RANT A PERMIT 1
met, ddress)
the .. I to hold tempor d .. ( the body.
(Uq tater r per�pnl+avtng charge We rpee) t , remove,or rwise s se of[ to how])
Dated 19 (Signed)...... ... . ,Q...
a
- . Lora Re straw •'1
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common currier, in which case a Transit Permit (VS No. 62) is required. .
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