Stevens, Lenita Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lar 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. 5/
Village y�
Dist. I\'o. .d/....County ."i.JI.h. ..s_..� or City . /D'el—• c Q
(If city, give st set addr )
Name of deceased ...... . .... .. .. Veteran
•
Single, marrie , widowed,
(If eteran. give name of War)
5e olor. r divorced (writeithe word) Date of /c- 9
Age O Years.... ... Months... .....L . Days Birthplace... .. . . . ...�7..,.
Cause of Death
Certificate was signed by M.D.
Address •,
Place of Burial (or Removal).. \ ,,
..._
(If body is to be tem rarmy held, H I splice later) / i
Cemetery -- t..,�.> Date of Burial ..A.. ,, 19.
(If body Is to be t porarily held, fill in space later)
Thq Certificate of Death containing the above stated particulars, having been presented t e, 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, and< on the ba3isereof'k H BY QRANT A PERMIT Afg c.e)
to d
Na (Ad s)
the . . . . ... ...... . to hold temporarily a ... . .. ! ..... he body.
(Unde>ytaker or person having charge of corpse) e,or oth se of(state )
Dated .r... J .r.' l9 7 .. (Signed)... , /.
Local Registrar
This Permit is fficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ject 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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