Friedman, Mary Prtt
43,3_441 'L C i NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ra" 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. / 9
`/ Town, Villa MeAsteNofDist. Nos... (�ci( County .... .. ... .. or City..... . i 1`l
94/24-- -
ingle, r (If city, give street address)
Name of d ased • , Veteran "/')`//) C)
(If veteran, give name of War)
married, widowed, °` ~"
Sex ,_ , .., .. or divorced(write the word) i4��o` `-� Date of Death ... -' - /3 19 2,,5�
Age.. . .... ears��...�'." ,,]Mont vi Days / Birthplace...
Cause of Death
Certificate was signedby ..(. ./.`.) / M.D.
Address �.. i.-L` L6
Place of Buria Removal :.. . C, . f
(If body is to be a porarily hel , i to ce a -
Cemetery .... ...... Date of Burial � — / 19 9 S
(If body is o emporarilyIt'd, fill space later)
The CERTIFICATE OF DEATH raining the above stated particulars, having been presented to me, after careful examination, the
same earing to be COMPLE E CORRECT, AND TISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, h e recorded it 'n my L c Rec r.I Iwith the ove stated Re stered Number, a on the basis thereof I HEREBY GRANT A
PERMi/
O r
ame) (t1a ress}.�
t ��, � .; .. . to hold temporarily an the body
(Un erta or person haven charge of ygrp�c) er, remo or o wrs dispose of (state how))
Dated j-/, 19 .j...3 (Signed) '�j�
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t 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.
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 L11., .•,-r was \3//yl 75 19
(Interment or Cremation)
4-4
(,Y me of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
-
(Signed) vr c:✓�/
Cievt (Person ,i Charge)
Address"?/ '/O7 ff2L 1
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. Uric)
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, 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 116
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.