LaCarte, Zola Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 CERTI ICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No. ._....7 7
Village
Dist. No,' G6/County..... ?1------e:L7-7-1-.-4— or City ,':✓. i-. `.7: '-L--
•~ (If city, glue street address)
Name of deceased Ya-e--er--. ..... .ZC..1 � 1.1.<r
Veteran
Single, married, widowed, (l( "`(e` ' give mine of wu)
Sex V/ Color ,E!,E� or divorced (wnte the word) Date of De th.. ":.. 19.`v�.
Age ...Years onths.. Days Birthplace , .,2 &'„ /' .
Cause of Death
Certificate was signed by .. M.D.
Address --- .»'2 s.�• r
Place of Burial (or Removal) O(If body is to be temporar y held,�tl401.—
)
X7. //,,
Cemetery .. ��-- . �.e�ca ��.., Date of Burial ..:���:��{yr....�. ..19
(If body is to be temporarily held,ff 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 ac9pted the same for registration, have recorded it in my Local Record with the above stated Registered
Nurnbeild o a basis t e I HEREBY GRANT A PERMIT )
Na A '---- . (Address) /
the .. . . ...-e° - to hold temporarily and...e..."-- . ... .... a.the body.
(Unde Y r or pe having charge of corpse) (Inter,re oth [state I)
Dated .,2- 19 .7 (Signed) .
Local
This 't is snff lent for the Removal (and Interment or Cremation) of a body to say pert of the State (eabject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Tranait Permit (VS No. 62) is required.
ENDORSEMENT OF SEOCIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMSATIONS
ARE MADE
Date of was 19 ✓ 7
(Interment or
S 4°2, ,t1,/
(Name of Cemetery, Crematorium, .01
tlArto p4totrE
Section Lot No. Grave No.
(Signed)
(Person In cha ge)
cr-
Address
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 UNDERTA.:ER 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.