Sherman, Jennie Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
„,„.._.....
OFFICIAL BURIAL (OR REMOVAL) PERMIT
£ 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 LACK INK.
Re;-red No.
oDist. '''‘ C untyil NV• Tz5wrr
Village
t at city,give street address)
Name of deceased. • re3-14:reAC
gle, married, widowed,
Sex ,...- "...Color.. ' r divorced (write the word
f 7
. Da eath 4 / 19144
Age 7 (0/- Year& oaths 44 pays plac 411/7.4..,
Cause of Death
•
Certificate was • by.... ... ... .. ... . . M.D.
Address. . c frArTree , //2 , y
Place of Buri legsmoval)
(--
(If body is to b te rariTy held,fill i s ace later) ,—
Cemetery i'....-.1.4k.,r.‘" .4.-4 4r4:411 Date of Burial 19.ft4
(It body is to b temporarily held,fill n space later)
The Certificate of Death containing the above stated particulars, having been presented o me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same f re *stration, have recorded it in my Local ecord with the abre-st4ted Registered
Nti e , arltivid;arcrle3asi e I REBY ANT A PERMIT /mega 017. y
(Name) (Address)
the to hold tem arily And "---- . the body.
/ (tlnde ker or personving charge ole(pae) . nter,remove,or ot 'se disnose o e ]
Dat . . . 19. 4--- (Signed)..„. 4/4drir - :1•
di ocal Registrar
This Pesufficient
is for the Removal (and Interment or Cremation) of a ..•y ii any part of the State (su ject to local
cemetery or other regulations),unless removal is by common carrier,in which case a T ansit Permit (VS No. 62) is required.
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