King, Katherine Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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— Registered No.__.._...._................._
Village ____4_,h_rt......4..,/ ....t.:,7_,/,‘,
Dist. No. . .County...
..... .. ri 2-'� or City
(If city, gi street address)
Name of deceased _ Veteran
Gam) Single, married, widowed, �, 1 t (If veteran, give name of War)
Sex. ...xl olor or divorced (wnte the word) //Date of Death /' / 7 19.6i
A .� Years.. Anths ..Da s irth lace ,
Cause of Death t�� . � /i G� "�^ P
Certificate was sigied by t � � M.D.
.. ...
Address...:::�4...1?. s�P. - '-.. . ... .
Place of Burial (or_Removal).,J�—`Yl- - �. - -(
(If body 1s to be teas rar14+held,fill is later)
Cemetery »:..r' k:, s Z ' �% �7,,,�.,.......Date of Burial -- c;;-2-- C:J 19.0../
(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 Re rd ith the above stated istered
NozMand on e bp� hereo ,I HEREBY GRANT A PERMIT
the ��? -Wit— Y..to hold temprily nd...: tl�(Address)/
e ody.
(Undertaker orye� n haying charge oof corpse) r , (Inter,rem ,or p a state how])
Dated / — 4 19.. � (Signed)y1 .... ..:.. ...
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)"f f a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in whit case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX'IUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREATIONS
ARE MADE
\4y
Date of�� C � was
\\G,7Z- 19 6 /
(Interment or 6r'e7fr trry
)
,41 y�"c. .�T-.L<:�--�i , - -/2._,c 1.et /.. ✓ �� l.!
(_. G- (Name of Cemetery, Crematorium, e ) �4
Section Lot No. Grave No.
(Signed) / e 1/2 C- . ,r..l]� t- ('
/ (Person in charge)
•
Address (Jr. l 1Sl C.- 1
/
Person in charge waist returzf this Permit to C'
the Registrar of his District within SEVEN (7) DAYS
fran 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.