Rukat, William Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 CERTIFI� T OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. egistered No. ((
Dist. N (4 6...1 County / a ,..-�
xe7,-....eleezeir.4_ or City (I city,give street address)
Name of deceased
Single; married, widowed, •
Sex Color �1 or divorced (write the wo Date of t3 19�
Age "z -- on ,A0-. Birthplace
Cause of Death i -
Certificate was signed by r M.D.
Address ,�: f i
Place of Burial (or al) .G�'Lr!J`.'?!4... ../ c"2^
(If body Is to be temp or rid,fill in space liter)
Cemetery Date of Burial 19.14
(If body is to be tem arily held,S11 in space later)
The Certificate of Death containing the above stated particulars, having been presented to m , after careful exami-
nation, the , e appearing to be .OMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ac d the same • r: stration, h,a�ve recorded it in my Local Reco with the ab stated Registered
Numbe .. . on the has'Ail*
.f I HER Q3' ANT A PERMIT �P�' er
the ..rfl.- ..,1 C. to hold temporarily an/�r` ress) the dy.
(U taker or person having charge of G���✓ ,or other isn [state how
Dated / corpse) I
19..4. (Signed)
Local Registrar
This Permit is flicient for the Removal (and Interment or Cremation) of a body to any part of the State (subje 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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