St.John, Rosalyn Form o&dL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
d' 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 yRegistered No.._....eg_`f.1.._
`h.d.0� Vi %/.��-ar't*� lam'.. r�,i
Dist. No .County.. ,�,�,c'w or City ,/f
(If city,give street address)
Name of deceased .�j/j. ( ....... ..( Veteran
Singl
married widowed (If veteran. give name of War)
frk, ,
Sex Ni Color or divorced (wnte the word)..`�.Tr`.4 Date of Death Lyj a 19... Y
Age 7. ...Years...no Months Days . Birthplace C- ..l,�
Cause of De�th ,.., .. ,.. '°
Certi cate was signed by e-°::;..,:;r,., -, ;g....14<s,, M.D.
Address k P. ,�`,, ..,
Place of Burial (or Removal) / / i r- 7r /
(If body Is to be temporarily held,fill in space later)
Cemetery Date of Burial 19
(If body 1a to be temporarily held, fill in space Iater)
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 ./4-'-
(Natflel
the �"`` to hold temporarily and (Address) fV
(Undertaker or person havingcharge of corpse) p y w)) body.
g (Inter,remove,or otherwis,,ttdf�of[state how])
Dated ✓,r 19 (Signed) . .e._., e.. .,.,� ,.
Local Registrar
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.
0- 1zG,
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CATIONS
ARE MADE
Date'6 l--1 -I was Z'`•%/-3--- 19
(Interment or Cr ticn)
''''32\ ' '''''' ''' ___,Z; .-----1-.
(Name of Cemetery, Crematorium, etc.)
Section Lot No.c% / Grave No. 9'
(Signed) -;(2 /.,...,.--/L-e C22
(Person in charge)
Address,Z isf z L e -
Person in charge mu return this Permit to /
the Registrar of his District within SEVEN (7) DAYS
fran 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 OFF1.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.