Fleckeustin, Dominick NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilfage, 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.
Registered No
4 0 . .5-6 o/
Town, Village C.D.-0,41k)
Dist. No. " County l& CiViti?"-) or City
(If city, give street address)
Name of deceased ia,,,,,:i ----/ti,, .,,,.,„ -
" eteran
Single, married, widowed,
(If veteran, ive name of War)
,-
Sex ---"AZ-C4--- -12-- or divorced (write the word) LA"'ej-02-41- Date of Death / 19 -5
Age S-- 3 .Years ---,ponths Days vett Birthplace
-71,,Cet-Si
Cause of Death
Certificate was signed by 49 --a) ' M.D.
- /00 oli._ ,r,(/ ,,a./ 7g4<.,„<„0
Address ,- -,7
Place of Burial (Teelovl) be-i--4,-2-,t- Ti -(/_- _,./a_L.._,..j_s
(If body is to be te ora lylield, ii I in space I r
Cemetery Date of Burial / — -2 -7-- 19 73
(If body is to he tempor , fill in space later)
The CERTIFICATE OF DEATH containing the above stated particu rs, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have re prded it in my Local R cord with the above stated Registered Number, and o the basis thereof I HEREBY GRANT A
PERMIT / e
to
ANart7y-_--
the .,..,a_.,---C--r...---4---e--e"-Z-- ---c-0- E--' to hold temporarily and
the dy
(Un ertaker or person havingcharge of capse) (Inter, r e, or otherwise dispose of (state how))
Dated / — /3 (Signed)
canigistacoeit.a.
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any par f the tate (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS M. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date ofc �� '��,.�t..:ti �was
(Interment or'Ci.
(Name of Cemetery, C,.ematp j.0 er )
//3 j,Zet
Section � Lot No. / 'Y J Grave No. /
(Signed L ' /�
'� (Person in Charge)
Address Z y lC
/u1(/ ;t—.
1/ �, �j -, •
in charge mu`streturfi this rmit to the Registrar
of his District within SEVEN (7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, 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 required, under
penalty, to report violations thereof.