Schaafs, Martha Form TEL IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ur 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 CERTIFIIC�ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No..__.._...._....._._
V
llage
Suffolk or City
Dist. No..5196 County City Brentwood
(If city, give street address)
Name of deceased Martha Sehaafs Veteran no
Single, married, widowed, (II veteran, give name of War)
Sex..F.mal(3Color.Wh.i.tte....or divorced (wnte the word)...Wiiilakze.d. Date of Death 8�. 5 1958
Age 77 Years 71: € Birthplace ekl. .Yo.r.k.
Cause of Death Ar.tie.x.'.7..a Gl.ex.o.ta. ...b.e.a„Y'.t...ata.ek.S.e
Certificate was signed by Herman Ma 1 ve s M.D.
Address W,..B..rentlr;.Q4ci, N.Y,
Place of Burial (or Removal).. ueensbury, N.Y.
(if body Is to be temporarily held,fill in space later)
Cemetery......liltr..x x'17ion....Gem°te.;k'y Date of Burial 8/29 19 Ei..
(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 Grant Funeral Home 571 Suffolk Ave, Bre tkioos1
(Name) (Address)
the tan e.r.t.ake.z' to hold temporarily and inter the body.
(Undertaker or persarge of corpse) (Iasi ,remove,o therwise ■nose (state h l)
on having ch
Dated a/27 19....58 (Signed). .... Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (enbject to l:,cal
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
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date,g2 2-22.. � wa.s ,-/ 19(6
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No:
(Signed) �J 4. ..f4---(�-�„ ie
(Person in charge) -`
Address
Person in charge mist 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," 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.