Hamelin, Arthur Vora VS.tL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to This Permit eau be signed only by the Lecai Registrar (Deputy or subregiatrar) 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.—.. .�1_..cF'_
s- CC/Pecan ..-//,�f. Village 4-e -'
Dist No.. t}►.. d< �:�.Y..�r.:?� or City „4�;,-
� (If city, Fri a street address)
Name of deceased (,�{.: .,'r�.4;6i //'. .4-�c-�
�n� J1, Single, married, widowed, (If vs an, slue name of War)
1`l Color. or divorced (write the word) jam'¢ Date of Dea .2 d 19.S..:1
Age .S'"" .Years Months ..Days Birthplace �: G ,...k:I... •
Cause of Death 7 zkL 4, Da s �,. ,
Certificate was signed by . ,,,, - M.D.
Address � A . �f 1
Place of Burial (or Removal) 4.. Zi
body to be temp9�r�ile holdall e "'ce nter) 4y�..„.. c.
Cemetery Date of Burial .L 6 ...Z .5i.19.t /
(If body is to be temporarily held,fll space later)
The Certificate of Death containing the above stated particulars, having been presented o me, aft r careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for regi ation, have recorded it in my Local Record with the above stated Registered
Num.=nand on the basis ie 1 I EREBY GRANT A PERMIT ''
10 /a
to f - / yv
. -7-
G '_"__' (1adre.a)the
to hold temporarily and... ...the body.
(Unde 44r or pa ., having charge of corpse) p y
Dated .. .. (inter. o othe a of[mate owl)
. : 19..t..:7 (Signed)
Local R
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the Mate (estbjeet to local
cemetery or other regulations),unless removal is by common carrier, 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
Date oft, r�l�-'Z r,-1 .� was ,A y 19 ,r 7
(Inter.ent or Cr tion)
(Nome of C etery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) ( ,�( /
�(1s. ron in charge)
Address C 47l G
Person in charge Host 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-
PENT, write across the face of the Permit the words
"No person in charge," aid 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 TSE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.