Sommer, Mary Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ear 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..23.
'7 Village //r'_
Dist. No ) `:C,1..County.......2L 2X �a.. or City �� � r
cfty,give street address)
Name of deceased L22Z. C .et .. Q (If. Veteran
In , married, widowed, (IF veteran, ive ame of War)
�/ g t
Sex. Iv, Color.... or divorced (wntt the word) Date of D a .... .....19..6...7
Age Years MonthJ. ..7 Days lace. . - �1.. 7,.
Cause of Death ti i,r.':!'� 4: ,,. .. •• r
Certificate was signed by . .. "cf".14.7.1'01//7:4-/-- M.D.
Address ... ... . ?rj.. ..:
Place of Burial (o> Removal) .LG. 8...40...eg-t.d..,...,-..riegla...g.Z.e.... ....... r
(If body Is to be te�mp�ly,�t,ld,Il�I�'space later) ._
Cemetery �'" ' U4 C¢ L.kz:y-z: Date of Burial / ,. 19.=*...;/
(If body is to be temporarily bel ,fill 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, a n tthto /�e,�/b`/a�sy th I44 /A•-/tglite GRANT A PERMIT �(/j (/ �j,, //'//„
/�/ g (Address)
the G G (aN%CL�
-a ?- to hold ten orari.y and. i• the body
(Undertaker o pe a having charge of corpse) r, move, the se e of[a ow))
Dated 19.t.7 (Signed)
It
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Mate (.abject to local
_.-ntery or other regulations), unless removal is by common curier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
d i �
Date of was / 7
19 tj
(Interment or
c 11/4 .
me of emetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) AAA)• OtotASS 4"dAd4
(parson in enare)
Address
V V V
./ ./.// /4;le'el
Person in charge oust 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," aid FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of Distriict 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.
L