Mark, Anna Form vs.st. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
is 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. ...j....L.. _..
Village
Dist. NoAlQ?.»...County.....U.Q. §.5silllf ' or City Tx°oys ;;..Y
(It city,give street address)
Name of deceased Anna Mark Veteran rio
Single, married, widowed, (If veteran. give name of War)
Sex ti Color W or divorced (wnte the word)...W7..C7.03,7 Date of Death 9/19/58 19
Age 72 Years Months Days Birthplace Rus.s.i.&
Cause of Death P.ulT11.S?Xkt.ry. .edtdrila.--Cry:.ain.orn .. .0.'1»...the.. .s.p3,n.Qo.
Certificate was signed by Dr. C • R. f Q lax M.D.
Address. 24 4.-1..t.b, Str.O.O.t.s....TA.r.,...11.Y
Place of Burial (or Removal) 0.1.eLP...E.4.12.s.4...T.Z...Xa
(If body is to be temporarily held,fill in space later)
Cemetery Tephli1a,b. Geraeter,y Date of Burial 9.21/58 19
(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 Robert Yl, Ise VI.UQ ..2 11—.1.
.
(Name) (Address)
the Undar.t.ak.er to hold temporarily and Lit.r ,,;,:...r the body.
(Undertaker or person having charge of corpse) (Inter,remoj o otpenvise,dlsoose of[state bow])
Dated 9/1913 19 (Signed). .............: ........,:..r ; I.o�al�rl�x�.-// ..-:test. --
egiErar
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. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
4 ;
i{ 7
Date of\. '\,: ^' - .l
was 1 19 S
(Interment or Cremation)
(Name of emetery, Crematorium, etc.)
Section Lot No. Grave No.
i 'N •
(Signed) +. •. ., _
(Person in charge)
04- '
Address 1 °, A14++ � � .4-/ 1640: iA,
Person in charge rust 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 tht. 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 louateu.
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.