Bakst, Yetta Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
c' 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 • CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No.__.._.45.ii7
Village
NoDist. o 6--C G j County - �.�.�2'x.�'.f•.z C
r or City -/�.� �%
, (If etty, give street address)
r+
Name of deceased. G . . s,. ,6..4.-47 Veteran .‘ {-c^--
.2 �-�- Single, married, widowed, (if veteran. give name of War)
Sex' Color. ..�:fcffi...or divorced (write the word) 4_ ? '..j Date of Del l•-,l-2-5 19 `-r5J
Age .�7 Years.,,... Months ..._..;Days Birthplace eta:¢::-rtsr-
Cause of Death
Certificate was sired by......... .4.:1. ; c M.D.
Address
Place of Burial (or Removal) A ` /,, , ';�r.� kez, 37 • y /,
(If body 1s to be temporarily held,..1�Lin page later) /
Cemetery _,, 1 1r... /..ec�.4x. -.CRz,,,i.., late of Burial A / a ,E-
19S
(If body is to be temporarily held,fill space later)
Thn 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 stated Registered
Number, Ltd /onn,-the basis thereof _I cUEREB.X GRANT A PERMIT
t0 j.(.�>,G4 sr� s^-.y (N/, .Gxa �l'fie tiT(f c:..:_... q ..r.�,...F. t,:
(Address)
the -e ,.r-- to hold temporarily and the body.
(Undertaker or person having charge of corpse) Inte., emoop or otherriae dispose of[state how])
Dated /a../ 4 41 19 -CST (Signed) �� -
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the Scats (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 INTERMMENTS OR CR1MATIONS
ARE MADE
Y .
Date of was 1-Z i ` 19 -
(Interment or Cremation
(Name of (hem cry, Crematorium,. etc.) - -
•
Section r Lot No. Grave No.
,
(Signed) )y/1.A1_./`` -- l ( L.li '�
(Person in charge)
Address 7 ij l.l.1 al i1 :I Q (f
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.