Floro, Mary Form vs.6- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
n' This Permit can be signed only by the Lecal 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 Village
Dist. No County..._..........:: ( -/'tt or City
(If city,give street address)
Name of deceased ' /7/(' Veteran
Single, married, widowed, )4/ • (If veteran. give name ei War)
ri
Sex ' Color % or divorced (write the word). I!/' -, G ' ' Date of Death 19
Age Years. Months.......................Days Birthplace
Cause of Death -' 1- »: ..-4J f - - (�,.4'1.444.:r1 ......
Certificate was signed by .::.- 'J ,- M.D.
Address .•..
Place of Burial (or Removal) ,, -••,f/'''
(If body la to be temporarily held,fill In space later) -�
Cemetery Date of Burial /- •.L.••k 19
5 �
(If body is to be temporarily held, fill in apace 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 ..:;... t
(Hama) — ( ddreas)
the . :..£a to hold temporari.y and. ' he body.
(Undertaker or person having charge of corpse) (Inter,remove,or of ad o of to 1)
Dated ;L../....�a 19 (Signed)
^Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of bed to any part of the State (.abject to local
aer ettn-wty or other regulations), unless removal is by common carrier, in which c e a Transit Permit (VS No. 621 is required.
Cad?? ce
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTEWAENTS OR CREMATIONS
ARE MADE
Date o � 6 3 ;
(Interment )
/17.--)
(Name of Cemetery, Crematorium, a 41.)
Section . Lot No.(� 7 Grave No
(Signed)5ii'
' e-gr-7Z
/�� (person In charge)
Address "/ a G A _A i'e
ki,,_;ta V/
rJ
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no perscn is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
SENT, 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 FIRlST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.