Canale, Ulise Form vs.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
O'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 WRTITEN IN DURABLE SLACK INK. Tow% Registered No—.....Y..,..........--
Village OQ,
Dist. No�BI County...».» or City % .tea "
(,� �• �_ --0 (If city, glue street address)
Name of deceased "l o.....
Veteran
Single, married, widowed, (If veteran, give name of War)
Sex I� Color or divorced (write the word) Date ofath �� 19SI
Age tt is Year. Months...........».....Days Birthplace a'"0-- '�
Cause of Death y.
Certificate was signed by 4. 'F M.D.
Address. 6v /30 xAt.. ....... ..
Place of Burial (or Removal) Ali . .
(If body Is to be oral held,fill In pace later) _
Cemetery...... ... Date of Buria] 3-4- � 19,)1(
(If body Is to be to. f�C_orarily held,fill In spec 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 SATISFAC!'ORY 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 thereat I HEREBY GRANT A PERMIT
to 4.N"d-C.v-�k "t .!L:1r'�M�......,....< !!1... % ., 7 -
am.) (Addresq
the to hold temporarkly and - the body.
(Undertake Jor person baring ebarse orpee)
( (Inter,remove berwf dls sof(state bow])
Dated i/ G 19 ,5 (Signed) ( c .1 Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 82) is required.
•
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
q/7z- -
Date of 1 was 19
nterment or Creation)
.....'
,./-4,,,,, „..„...4----
(Name of CCe itery, Crematorium, etc.)
Section, 4 If Lot No. ` Grave No. t. ,
f
(Signed)
(person in erarte)
Address 2ttp -Wei----, �/j/j(-
C ' ' '�W"`� / r /'
Person in charge Dust return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
SENT, write across the face of the Permit the *lords
"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 THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.