Jacobs, Alex NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Vilrage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CE TIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. CO
Town, Vi � R •'ste No.
Dist. No. �r� a ( ounty ...... . or City ,,/t-w+'1�.. 4-1--1
(If cit , 'ive stre//e��t� //,,dr,ess)
Name of deceased ... Veteran - lr.(.l &
(If veteran, give name of War)
Si , married, widowed,
Sex .......... or vorced (write the word)?ya4A/(--52-4Date of Death . -c?.. 197
Age 7 Ye nths y Birthplace
•
Cause of Death .... . / ...
Certificate was signed by M.D.
Addr ss - y
Place of Buria r Removal
(If body is to be porarily hel , i i ace a J
Cemetery . , Date of Burial �� �S—
r) 19.�fr
(If body is to be temporarily h Id, i i pace at
ill
The CE'TIFICATE OF D TH con fining the above stated particulars, having been presented to me, after careful examination, the
sameparing
to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, h. recorded it in my Local Record ith the above stated Registe ed Number, and on the basis thereof I HEREBY GRANT A
PERMI i I
to .. 4.. . . i . ,�'
/ �,f me G� (Aadress
the edl ., 1 /. to hold temporarily and ,- l the body
(Under akepoir pers n .aving charge of cor se) nter, emove, or otherwise dispose of (state how))
Dated /- - .. 19 �y (Signed)
o
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t any part f ti.e State (su ect to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Pe it (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was 19
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in Charge)
Address
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 UNDERk
TAKER MUST SIGN ABOVE STATEMENT, write across their"'
face of the Permit the words "No person in charge," and
FILE PERMIT WITHIN THREE (3) DAYS with the Regist
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 required, under
penalty, to report violations thereof.