Fisher, Jerome Form vs.gL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir This Permit ,rs.n 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.._.,.344.............
�('
Dist. No..a.. ��.�.Cotln :? - Village
or City
/
D (If city, give street address)
Name of deceased . . �-"`^' - ��- Y Veteran -l-mac
` (If veteran, give name of War)
Single, married, widowed, ,n
Sex.....}..LL......Color or divorced (wnte the word).14� 2. ..............Date of Die,
4/./,..27..t.
196A e " Yea s ....Months Da s _ Bi l eCause of Death ... .. �- r � . . . � '
Certificate was signed by f
M.D.
AddressA -
Place of Burial (or Removal) ,.,, � o 4a,T.�c `//'/�
(If body is to be tomos�Xly h id,fill g(2s a later) / / /
Cemetery /'.I . .r:'G A,4.7 :�`. -? ' Date of Burial o �/..:3 u 19. 1..
(If body is to be temporarily held, 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 SATISFACTORY AS REQUIRED BY LAW,
I have accept ;the same for registration, have recorded it in my Local Record with the above stated Registered
Number, is the asis tketeo I1,REBY GRANT A PERMIT _
to Yu �t' "' , /�
the ( (Address)
: .�- o hold temporarily and -A— the body.
(Underta r person having charge corpse) (Inter, remove,or otherwise disnoae of [state how])
Dated 6 19..�f (Signed).4, ;
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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date was {�y/� 19
(Interment o ) //
"/ e •
I;2,r.
(Name of Cemetery, rematorium, etc.)
Section Lot No. Grave No.
(Sued)
(Person in charge)
Address ((' l -� --.�'- k�
7 l�!�
7
Person in charge must return this Permit k
the Registrar of his District within SEVEN (7) AYS
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.