Seaman, Michele Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fa 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 CERTIFICATEC OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town4
Registered No.__..��_.._ ....F.......__
��� Village
Dist. No` County.. K& W 4..s or City ra .J
a �'� ((JJ /k (It city, give street add
Name of deceased.. 1s11:1.GL..... y ; ,��1k Gt«2,t..1�/.lC.r.'. Veteran
Single, Married, widowed, (If "«.n, give nameof wsr)
Sex �J Color �CV or divorced (write the word)...... . Date of Death c ' .,. e-___ 19.�f...5
Ageg •.�..Da s Birthplace tiiQ. " 4f
Cause of Death iti... . . i
Certificate was signed by �.. M.D.
Address L —frw �: f.
Place of Burial (or Removal • ltY..' G� -�-� 77
(If body is to be to porarlly hell pace 1a
Cemetery I . ' ' s f=" -- Date of Burial .E:c.< / 19'�." —
(If body la to be temporarily held, ft in space later)
The Certificate of Death containing the above state particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, C RRECT, 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
Num , on the basil thereof :I HEREBY GRANT A PERMIT &6
JCQ -)1,.4 .
the to hold temporarily and .. the body.
(Underta r person having charge of corpse) Inter re or othe se dlsoose of(s to how])
Dated �rf�/," 19 ..I'V (Signed) �1
.... Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR POISON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of tL was t ; 19
(Interment or Cremation)
(Name oft Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
•
(Signed) 1 �.� C
(Person in charge)
—1
,`Address . ,_ �.. a �_
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
7 FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE,
MENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.