Klein, Baby Girl Form ITS.Si. NEW YORK STATE DEPARTMENT OF HEALTH �l JJf `7
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er 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-,:..Z�..:_........_.
- _. Village
Dist. No County........ »..» ..: :>., or City ,. .4, ,„/
(If city,glee street address)
Name of deceased - Veteran
Single, married, widowed, (]f veteran, Give name of War)
Sex Color or divorced (write the word) / Date of Death /7 19
Age Years Month Days Birthplace .;a �- '
Cause of Death Fit, L a-/
Certificate was signed by GJ , ., ,G(..Qsx M.D.
Address
Place of Burial (or Removal) ,
(If body is to be temporarily held,All in space later) /
Cemetery Date of Burial ,l.,l 19
(If body is to be temporarily held,All in space later.
Thq 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 �.�., „...
(mama) 5/ r.-.. (Address)
the G to hold temporarily a - ,.,. •••• the body.
(Undertaker or person p7aring charge of corpse) ter. r • ,' o e se dispose [state how])
Dated ! 19 (Signed) J--
*sutras
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (ws`jeet to local
cer^,etery or other regulations), unless removal is by common currier, in which case a Transit Permit (VS No. g2) is required.
L 442_
ENDORSEMENT OF SEXIDN OR PERSON IN CHARGE OF
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date2.;1-76-I-Z—.1' wasL/e/1 7 19cl7
(Interment oriiun)
( of Cemetery, Crematorium, etc.)
417‘
tion Lot No. Grave No .(�
(Signed) �e'J" - '9/ t
(Person in charge)
Address Kli/ j'GettA . s-Cl % { -749
Person in charge nest return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
RENT, 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.