Lazarou, Elthemia Form TS.OIL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
M. This Permit can b• 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.._..',; /7.S'
Dist. No / Village
County..._....... �' � .. or City
(If city, give street address)
Name of deceased 77
.r1 ... Veteran ...\z�1
, Single, married, widowed, (If veteran, give name of War)
Sex 6-�£olor J�.. ,. or divorced (wnte the word). /././/1,.. ,: Date of Death i - '/ 19
Age 7...Years Months Days Birthplace -t- - 5` 't....._.
Cause of Death ,,- :d.:? Ct:/2f CCti-r t
Certificate was signed by i t— — M.D.
Address —_,
Place of Burial (or Removal) - J
(If body is to be temporarily held, fill in apace later) f
Cemetery Date of Burial /.. 19
(If body la 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 stated Registered
Number, and on the basis,thereof I HEREBY GRANT A PERMIT
to i"l /'' 22
wame) c- (Address)
the ...::�:•f- ' _-- to hold temporarily and _- the body.
(undertaker or verso Mavis charge rge of corpse) (Intermo e,,oer� er�vf� apoee of [state how])
Dated /a.// cs' 19 (Signed) � .. le `
. Reglstrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 'late (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 INTERMIINTS OR CREMATIONS
ARE MADE (. /,y ,
Cn-t c-&-e--6 .
'_ C+,
Date o '��-•---J ��=�� 19 6 ."
-- (Interment Or Cte Vino)
' / J
....4 '""( ,, ,..4(e..e.----- (7.7- 7-A.--e-
( sue of Cemetery, Crematorium, a .)
Sect:� ' "�''eo ,1- Lot No 5 A Grave No. ")--
I---1� r
(Signed) ���:-G�i_ - {/�"�c�- . 6
(Person in ch& ge
Address i.)1 G any �au_`r`" . ,- �
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.