Nichols, Walter Form VS 6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
er 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. `
wn Registered No._-.Z. .,1....._-
Dist. No2..0 Ir/ Coup lr' :.. = 1r
,,1 Q /f��' (If city, givstreet address)
Name of deceased G..`/...0-' (. X!' . -<
Veteran
f. i Single, married, widowed, (If teleran, Slue n of War)
Sex Color.ft'' or divorced (wnte the word).`.:.:;. Date of Death 19 6. --
Age 7 Years onths Days irthplace. -`_r-' ... <G....r-,.: 'h.
Cause of Death-.: -. . .:-z ' %.,. :�.:...:.r:-.— __- _ _ 4.--- :..� _,
Certificate was signed.. h .. ;1,,4ti,,, M.D.
Address 1 12
Place of Burial (or Removal) -- -�� �• ry�- r �r� :.. .......
(If body is to be temporarily ld,fill in space hater)
Cemetery —e-=-r..-x-- li:;�- �, Date of Burial 'V" J. 19.6. -
(If body is to be temporarily held,till 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 state gistered
Number, and on the baste th BY GRANT A PERMIT / 0 p
to. ---y-- •e-e---4--'---'`- -k="---- -„ - ,I r
r (Na (Address)r t
the � :---z:: to hold temporarily and..:. .. .... :z:. ... N. e dy,
ftWertaker or pe having charge o;corpse) (Inter,remove,or erwise dlsnoee of[state how])
Dated....,..t. .. .3 19../..�-.7.,`L._ (Signed) l�l '
Local Aepatrar J
This ermit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (*abject 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 PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Late of .h ,.� . !19 Z--
(Interment or ) r--=�—
(Rsme of Cemetery, CrevAtor tun,
/ etc.) 3
Section /71 Lot No. /S 71- Grave No.
(Signed) Z.f_z.;`
(Person in charge)
(
^
Address �' Z
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 OF11,NSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.