Kautuawitz, Baby Girl Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit ;-ea 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._ '5..�
Village -�
01-t
Dist. No5-6° i Coup ..... 2 +
or City 1(., ,L.- "J ,2'E� --
�••�• ` v" "'r � � ' (If city, give street address)
Name of deceased r Veteran
Single, married, widowed, (If veteran.
give name of War)
SexLt4A Lk) Color P ` or divorced (write the word) Date of Death.., � U 50 19-5—
Age .-- Years onths ^ Days Birthplace
Cause of Death !' : .
Certificate was signed by / M.D.
Address ,1.. ... :.�.� '� -�a
),, ,_ ia,jeL.
Place of Burial (or Removal) 4I •••••
(If body is to be te 'arny held,fill in )
Cemetery .u3:�c >.:4 / -...• ��
a %. Date of Burial 19
(If body is to be temporarily held,fill in space 1 er)
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 abov stated Re istered
Number, acpI op Ahe basis there_ of HEREB GRANT A PERMIT U /t
the , ,_ ,`,_NamsJ al to hold temporarily and the body.
(Undertaker or person baying charge of co ) (Int , on,o thervrise di n se tate howl)
Dated... ,kt _ ), 19...1..I (Signed) j
f Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a botYy to any part of the State (eubje to local
cemetery or other regulations), unless removal is by common carrier, in whit 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
Date oftg•-•^61-^J was ` L.> A > 19
(Interment or Cremation) 1
WV('.
(Name of Ceme ry, Crematorium, etc.) !1
Section Lot No. Grave No.
(Signed) )\AV/"----i"--�-;
(Person in charge)
Address ) ) J PA. LI 41:1 iJJL
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.