Mc Ginnis, Lulu Form VS.6L NEW YORK STATE-DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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. Registered No. /G
Dist. No 0/ County Town
Village
Or jr7Le:_,,,_,c,t_dCi (If city,give street address)
Name of deceased
Single, married, widowed,
Sex Color or divorced (write the word). - r...Date oeath 19
Age 6 Years — Months ` Days . , Birthmglace C/`�1_` ! ' , >2.
Cause of Death - b . .,.•
. ... . .. ... . . .
Certificate was signed by y��✓ ... ..... r M.D
Address r ` . .!'— .el. 7-7 �,
Place of Burial (or Removal) e ��.- c� .. .. .,. xfc.,c.I ,...--4.4..
(If body is ty.aei temporarily held,fill 195 space later
Cemetery --4- 4..). �-?.- Date of Burial d. — 19. i<,,
(If body is to be temporarily 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 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
Numbe don the basks the f I EREBY GRANT A PERMIT
to
d (A as)
the %1-xt..uf.�-- to hold temporari body.
Undertaker person having charge f corpse) is_ t
Dated '' ' �.4,`- 19.,fir. (Signed).... ....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sub' ct to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is re uired.
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