York, Elna Perna VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ft This Permit call 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._....._...._........_ .�
/ Village
Dist. No./0/ County........ or City
(I1 elty,al street address)
Name of deceased Veteran
Single, mar • , widowed, (If veteran, give name of War)
Sex.. - Color ��' or divorced rite the word)✓.lr`"��")--�Uate of 9— C 199•..
Ag . ,.3 Ye Months.. .........._..Days Birthplaces .... ,
Cause of Death .. ....
Certificate was signed by `.� M.D.
Address -
Place of Burial or Removal) 3::; ---30
(I2 body is to be rarll el n 1 ace later)
Cemetery.. • I Date of Burial 7 - Cl 19.1 .
(It body is t be temporarily hel {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 SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same f• registration, have recorded it in my Local Record with the above stated Registered
Nu theas' /.e
� reof I HEREBY GRANT A PERMIT ,
to 'b .•• e
( ,. ) (Address)
the / to hold temporarily nd. the body.
(Undertaker or perapn having char s�.o�corpse) (I ova,or othezige of[state bowl)
Dated"!" i (Signed)
Local x
This Permit is sufficient for the Removal (and Interment or Cremation) of a to any pest of State (e>tbject to local
cemetery or other regulations),unless removal is by common carrier,in which case a ransit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
I
3 of2 ,/-
Date was 195j
et
(inter nt or Cremation)
cY v
(Na of Cemetery, Crematorium, etc.)
Section V —1 Lot No. 16 . Grave No. 6
(Signed) P
MD son n carp)
Address ,.a `4..›o
Person in charge mist return this zmi 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-
RENT, 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 TRAM 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.