O'Brein, Laura Form VS.6L • NEW YORK STATE DEPARTMENT OF HEALTH
'.-_- OFFICIAL BURIAL (OR REMOVAL) PERMIT
vir 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 RABLE BLACK INK. RCN fe ere No.
Tevvn-
Dist. Nd/.11.. .C 01, Village '`I ./ 17`,
(If city, give street address)
Name of ecease. ... . ..,, f��J
Single, r ed, widowed,
'
Sex �''"- Color... .. ../...... r divor d (write the vor Date of ' / 19
Age./..7 j s Months.. 44•• .-) ..... .....firth lac :.
Cause of Death. „• _ p ... k.
Certificate was signed by. ..... .. ... .. M.D.
Address 4714,0't ... .J;�a •
Place of Buriar Remova .,,:...
(If body is to a e ol�hrily held, 11 sp later) /
Cemetery.. ....,�6t ,,.�,,�.. .. ...:t Date of Burial.. • 19 t7-4
(IP body is to a temporarily held,b11 in space later)
The Certificate of Death containing the above stated particulars, having been presente to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hay c ted the same f r registration, have recorded it in my Local Rec rd with the abov ted Registered
Nu , d on the basis :HEREBY GRANT A PERMI�7"'
to... .. . C o� .-eau.
'` ( me) f ��_ (Address)
the ✓ o hold tempor ily d the hod'?
Un erta. r or person having charge o co} se) /� nter,remove,or o se disno `of h ])
Date; �* s- 19... ....il'E (Signed).r.�.. . ... ..
/� .• Local Registrar
$ is sufficient for the Removal (and Interment or Cremation) of t6 any part of the State (subject to loyal
cemeteryL•.r other regulations),unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
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