Mattice, Iva Form vs.SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir This Permit can be signed only by the Local Registrar (Deputy or subre trar) of the Primary Registrationeict (To ,
Village, or City) in which the des occurred after the FILING and acceptance a CORRE T AND COMPLETE C 17T F
DEATH, LY,RrITEN IN LE BCKI LANK. Town egis ered No—.
(If city,give street addyets)
• m .f deceased , Vetera
valet . iv name o War;400,
' le, married, widow /
1
4 / ,
t., • .lo orc (wnte e Date o/ie. •
, 4Pir i Air 1-
Age .4 Years
/ cirth.la e ../4,400000yx.--.-4,),
Cause o4 ath /
Certifi .te w i d by / ati41404440, • i D.
li.dr .
Pl. 4f Mei ..
(I,'... o • te 1 Id II in 141a' 4
g •• le Date of Burial •St.5 0 194,
(I body is to be temporarily held,fill in ace later)
Thu Ce • sate of Death containing the above st particulars, having been presented to me, after careful exami-
nat. e same appearing to be COMPLETE, ORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have cce led the a for regis ion, have rded it in m F.cal Recor with the above stet Registered
Nu nth as' t ER Y A PER
o.
ddress)
the to hold tempora "• t-a-id:--fr the ody.
( dertaker r harges:K7 otherwise ose tate Dow])
Dated .19. (Sired).
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the tat ( ject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 6 • required.
ENDORSEMENT OF SEXTON OR PhESON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE C CCU,G2.
•
Date Zj, w4//�v 3 a- i9 /
nt or Cremation)
(Rare of Cemetery, Crematorium, e'tol)
Section 7
Lot No. Grave No.
(Signed)tr2/W—Z2-4-:" XY C-P 7l,
rain charge)(Pe on
Address
Person in charge Heist return this PermiVto
the Registrar of his District within SEVEN (7) DAYS
frog, 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.