Berkowitz, Anna Form vs.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dr 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 ow Registered No._
Village
Dist. No...f.n..L....County.......... orCity
(If cite, give street address)
Name of deceased..(,��.r�- ..j-r. .....b... Veteran ...,___'
Siag1e uiaiied, widowed,
S olo x—1 , ed
(If veteran, give name of Wu)
r. ... o( ... . . . . .../..6. 19 S.t
Age ..a.L ears Months. . 4. D. ays Birthplace..
ch,
Cause of Death..... . . —
Certificate was s ed by... .. _
i M.D.
Address... .
Place of Burial (n�r—Rerere 1-)...,1. \lnq.QJ .
(If body is t be temporarily held, till in sp ce later), I /�x
Cemetery. . . Date of Burial 1 .17e 19
(If body is to be temporarily h in space ater)
The Certificate of Death containing the above stated particulars, having been prese. - d 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
Nu on the basis t reof I HEREBY GRANT A PERMIT
(Name) , (Address)
t, to hold temporarily and.... the bo y.
(Un ertaker or person h�ate�ss charge of corpse) (Inter, remove or otherwise dispose of[state howl)
. . l t.vCSc-N 19...b4 (Signed) .. ... ...L...... .
Local Registrar
it is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
• other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
nfl
.=
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS .
ARE MADE
(
Date of '=',: 1,1„-S-'Y't" _ _was .,,�� .� ,' ' 19\ L
(Interment or Cremation) -'
1r''.; 11 '
f � ' jut,
• (Name off' Ceme1 ery, Crematorium, etc.)
Section Lot No. _Grave No.
(Signed) '_-7-1.`�►/�-/ ( .J� ,,.) '
(Person in chargel
p a
Address 7 I ,t , iLl' TL ,)cA ..
Person in charge mush return this Permit to
the Registrar of his Distritct within SEVEN (7) DAYS
from above date. If no peon is in charge, the
FUNERAL DIRECTOR or UNDERT R 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 DIRE('TORS and UNDERTAKERS
violating the law relative ;to the return of permits
are liable to a penalty of1NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLAR4 FOR THE FIRST OFFENSE.
The law will be enforced:; local Registrars are re-
quired, under penalty, tp,rfeport violations thereof.
t•