Cohen, Ester Form V&et NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be signed *sly by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING anti acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE SLACK INK. Town Registered No._.. .zi'./Z
Village .i
Dist. No •S�` County ... .g..4.-22 1Z or City :,,f :r.4,,, 0 -
'Zu / 1/-4s/L (If vet gave street address)
Name of deceasedVeteran ';
(1f veteran, give name of War)
�/ Single, ced marriedw, widowed ) �Sex / Color..,i1 or divorced *ante the word .) .:. Date of Death...:7...: . - 19
Age f ..c ....Yearsy Months: Days Birthplace rf �'� `t
Cause of Death ._.irkc. - .
Certificate was signed by ...(bt:L6 ...... ... '-'� M.D.
Address :. .. .,.. ... ..........,�
Place of Burial (or Removal) 41.4.7.)7...i...,&6... f .. . .......... .. ;!
(If body is to be temporarily held.till in ewe later) 7
Cemetery .: .i..:.i.:4'.......yr..4. :. 0 Date of Burial . ... ..,fit 19..:$�.-cE
(If body is to be temporarily held,Al yin @pace later)
Thn 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, %od o e,basis thereof I HEREBY GRANT A PERMIT
to .. ... .J l..!� ! f.V"'s 4.4.�6(.�.�:.Y..l.•. 11<.. e�� .».
t mg) (Address)
the A...�.¢ f.� a.eik`zr" to hold temporarily andk` * the body.
(Undertaker or pereqn having charge of corpse) . (Inter, mo dispose of (state bowl)
Dated 57 19 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part e1 the Slate (*abject to local
,:er- exry or other regulations),unless removal It by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXiUN 0R PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of &- L
Was / / 1�(Inteet or Crest/tion)
(Name of Cem ry:\irematorium, etc.)
Section Lot'No. Grave No.
>j.
(Signed) ..,
Address I 1 '"Vail, , . _ , -'.
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.