Goldstein, Celia Form vs.ilL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 Registered No—A.4C
Village
Dist. No -5-Ca./..County.....-.7PC,--P1'2" or City %4g.
(If city, give street address)
, --- -:,-
Name of deceased . . Sk-.6.:19.4r.te&P.'.c1.... . . '...,
Veteran 2-c-,e-
(If vet n, give name of War)
Single, married, widowed, - ....7A:‘:. i —
k .
SexN.7.44-lakolor.ie. ...or divorced (write the word) ,,..er..d- alf/Ci Date of DGgi 19S-S
Age 33 Years — Mooths ---- Days Birthplace
• .-...
Cause of Death......
Certificate was signed1 -e-Jr--1.17Y4Aer--• .44.-tg-'6.--e- ri - -77 ivr.D.
Address
). a...:..
Place of Burial (or Removal) T 4 ...9-.......„.4.4.... ., Y .
(If body is to be temp held,"....11inz:tlfa 82.7,1
Cemetery Date of Burial , 7Q.,....1.7 6 19 S-(It body body is to be temporarily held,All space later)
,..e-
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 iz .my Local Record with the above stated Registered
Numbert: the b. thereof I412REBY GRANT A PERMIT
--N7Ce4..,
(Name '''. -t-- (Address)
the .ga-.1.. . 44'..e..i- to hold temporarily and the body.
(u dertak Oor pe a having charge of corpse) - 11(JI2241.:,..rente,or othe se disnose of[state bow])
Dated'
/r• • , 19. .4:-...r.- (Signed)
' Local Registrar
This Permit is su dent 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 PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of s4�Lt.�►+..W[ as_ �F , .�, , e 4..,
(Interment or'.Cremat on)
•
•
(Name of C etery, Crematorium, etc.)
Section Lot No. Grave No.
•
(Signed) y_. ]] •
(Perr#aog 'charge)
Address L,) Y4-+10. .7y 4fij
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.