Canale, Fiorella Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir This Permit can be signed only by the Local Registrar (Deputy or aubregistrer) 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 2 u -
Dist. No County.. ... or City v c G` 4Y7_ '�'
(If city, give street'A dress)
,
Name of deceased ,,,46I,-x �{'," L.'-• - -_. Veteran
r°Single, married, widowed, (If veteran, give name of War)
Sex Color...L'.. or divorced (write the word) �;�' Date of Death.. 1�w ....T 19, .1
Age r�'' Years Months Days Birthplace :-��G: ..�:.�K�
.e'
Cause of Death 'V. 1' � ���///
Certificate was signed by , M.D.
Address ,4.4( -
Place of Burial (or Removal) 1<'
(If body Is to be temporarily held,fill In spacib .ter) , ••
�, ,/:W 19
Cemetery .�►`��.r•,. . �-- .` 4a.r/.•: .Date of Burial ���-1 dye` •."
(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 registration, have recorded it in my Local Record with the above staled Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT ) I ,cif-. - ld
(Name) _.. (Address)
the to hold temporarily and ` 2= L, the body.
(Undertaker or person ha pig charge of corpse) (Iotee-, emo.Eo o erwise dispose of[state howl)
Dated / 19 (Signed) .C� :-.. � -9 '.
ar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (.abject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. rsa) €> required,
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
r
Date of ,/f (J. L - /I ?rr--was t (
/f(Interment or Cremation)
(Rase or Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) /'.ee,' d6g1404"‹__A
(personA n charge)
Address 6 . 434- ( 0 0
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
ri- frau above a e: If b erson 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 change," 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-