Bromley, Marc Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr. 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._..._...._............
Village
Dist. No...k..Q ...1.County.�..� or Cites � ... •
` (If city,give str ress)
Name of decease `AA 71r.... °.� er.Nd. ' ..
` _ S Single, marri� idowed, If veteran, give name of War
Se� ...Color\.1.d... .or divorced (.'"r e the word) .. Date of Dea ..
Age Years
g � „d ►�... ...... ......Days` irthplac� �.. .... . .
Cause of Death .. ... . . .. ..
Certificate wa i y'S, . . .. .. _ .... ,,,_, ----- M.D.
Address... .. ..•••• .
Place of Burial (or Removal).. ... . . `''....s .-121, `--V\
(If body is to be temporarily held, fill in space later) //��,, �
Cemetery t '- t( Date of Burial �,...1,. ) .....19 %
(If body is to be temporarily held,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 r 'stration, have recorded it in my Lo 1 Record with the above stated Registered
Number, and on the baths t eo I HEREBY GRANT A PERMI —1A t
auto (Address)
the . .. .a.X..2",a. o hold empora y d ♦ the Kos
II derta r or person owing charge of corpse) (Inter,remove, [state WI,)
Dated .'t4"C • {.. . .19 .t~� (Signed) Q. y
G-. Local Registrar t — ,
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
C.. &ta--L4' Cat�Ct..
ENDORSEMENT OF SEX'lUN OR PERSON IN CHARGE OF
PREMISES ON WHICH I 31'„13 TS OR CREMATIONS
ARE MADE
Date of wa�'s 7,%/ 19�5
(Interment r C )
6/1
(Name of Cemetery,) Crematorium, etc.)
Section Lo No. } Grave No. 174
(Signed) i :72e'
/(person 11 charge)
Address ' 7!/ �"z-'
Person in charge must 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.