Barlett, Peter ------97'_`.:
Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. Town gagistered No.
17 .
Village
Dist. No,..7a .V...Coure .ati•-;"4---s - or City
(If city, glee street address)
Name of deceased -fe..,••• -" ---- VjAjeteran , of
e>r-1P, y sive yi eo
Single, ied, widowed,
S Ai- Colon/eV. or divorced (wnte the word). - Date of Pea
e52-
Months
7 .D s Birthplace
• -
Cause o Death
Certificate was signed .. . . ••• •• • M.D.
Address -
•w•
Place of Bun .. •riZemoyal)
(If body is to .. te.fi arily held, I space 1 r) ...-
Cemetery.. ifie ,..... . ...,,, Date of Burial // 19r-.../.
(If body is tO .- emporarily lid l ,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, hay ecorded it in my Local ecord with the above stated Registered
Nu , the b • ereof I RE RANT A PERMIT
to. . ... . . .. .... ...............
)
the . to hold temporarily and 3(Ad47:-''E/;7dnress)“Il4.
the body.
Dated
( ker person having chem. °rpm) (Inter(
r . ot disnose [state how])
- ..
(Signed) (
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.
ENDORSE OIT OF S ('IDN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTEflMETiTS OR CREIMATIQNS
ARE MADE
Date o �2�'CC2,/ was . r // 19��
(Interment off//LY'2'
_/1124-
(Name of Cemetery. Crematorium, etc.)
Section Lot No. _/4 Grave No.
(Signed) ./2l// �-
(Person in charge)
Address
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
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.