Simons, Pearl Form vs.SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 dee • occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN iir• •LE BLACK INK. Town Registered No— /
Viti-ag
Dist. Nof".5C County.... 4 ae:1 4:Z. ... OF-City TAelgekte4/1L'
I (If city, give street address)
Name of decease:61PP' ,e -a e
.4 )44.4-. Veteran
(If veteran. give name of War)
Single, married, widowed, \-\ . ij a
S ColorA....or divorced (wnte the word)...t3 ,,,, Date of D th..1.o2..-.-1..0..:- 76 19
eality#
Years '---, ,Month 4 .. ays - bv917.4.a4.7,thZtobeat,Lita.tati..C,
Cause of Death
-:D
Certificate was signed by. — t. M.D.
Address 5-4.._ 4
4,
, ....44..,--...) ( 447. 24
Place of Burial (or Removal) 4.2
(If body is to be temporart ace vir
Cemetery — ..4me. ,-.4.C44...(d.14,. ..&c,,_*-/ Date-of Burial /,Q77.11? d 19
(If body is to be temporarily held, 11 in space later)
Thq 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 ith the above stated Registered
N n the ba ip.ereof I HT ,..BLYce GRANT A PERMIT 0, .&31.4. aA, IS 444
to _ 4 ..0,
.,
'.1. —
111.1.0 „......... (A ream)
the IV, .4 to hold temporarily and the body.
(Untie I r o person having charge of corpse) re e of[state how])
Dated // 1976... (Signe
I'mal Rstistrar'44:46-'
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the (,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 INZERMENTS OR CREMATIONS
ARE MADE
Date o bras
(Interment or fCn __-
(Name of Cemetery,tel
Section / Lot No. 67 Grave No. _
(Signed) Lam/ ti
raon in charge)
Address X et,--a-1,1/
Person in charge must return this Permit
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.