Nichols, Baby girl Form VS.6L ? NEW YORK STATE DL AR MENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gm' 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 CERTIF~X OF
DEATH, LEGIBLY WRITTEN IN DU LE BLACK INK. gist red No.
ow
Dist. No -v e5/ County..
Name of eceased •/
...41.1.41.--,.._ , V411-4VP -4e)) /
/ , ;,r •. / / P city,give street Tess)
11, Single, married idowed,V / ��///
Sex.. ...., Colo or divrced ( ite the w .. ' / Date of � 19l`
�" �Y�!!�
Age Years - Months D- ` "' Birthplace ....
Cause of Death s^'�L ;. ?. . / •
Certificate was signed by �4 / , ',
M.D.
Address �/
Place of Burial (or oval) -3 5-e
(If body is to be tempo y held, 11 in s late . '2 19yc
Cemetery . .. .... . Date of Burial
(It body is to be temp arily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMP E , CORRECT, AND SATISFACTORY AS R (WI• $ BY LAW,
I have accep,= . the same for 'strati ye recorded it in my Local_,!.-c._-. with t - . .ov led Registered
Number, a. . on the b • eof I GRANT A PERMIT
terto
tP . iii.. ...../ddr•ss)
the . . to hold temporari y n ' '. } .the body.
(Un a or ersoa7ng charg o c pse) ,or othe e dis stat wyDated (Signed). /r Local Registra
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the state (su ject o local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is quired.
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