Pessolano, Anthony For V&IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 • tered No.
,--- Village
...--7-
Dist. No...2.44/...County....... ..1. 4.e—a1/ or City ..e4--Z -&-el )2. ,..
..,..,A _. 11..its i f
?ti -ntsite -C,o, )
Nam of deceased .a.---"je- or city, give streer%eas):,
Veteran
Sex. 4412/....1.Color..
)77
A.&Sorinei divorcedri(edwn ctil(i)
-(write
'-re-Als:vIevdt;rd)...:4.2,---
-74--eZ., Date of 1-.) . (If veteran. live name of War)
Z .---7 ..
Age Years 7. Months... -;2.. Days Birth_place,-;- .a.var
Cause of Death........ -- ? ,g2.-.Z:e.-:-.a..'.--.- -- - ...-0-- - i.e..4.-e:-...4:-.)
"79
-,
Certificate was signed by.... - ...4-22- .#4,/ M.D.
'1 "--'S ' '
Address . -..1. , ZIT.? . ,-, ,.'" ,
- -7
Place of Burial or Removal) /41---i-c-L?4,---' . .....e4:t....e.e-.-ari-a..,‘,-- ,
(If body is to Wt*-1-,:ip silly held,it4i .spaice later)
Cemetery.. ----..`•-,,,,re-e, :„.," "T..!.nr....a...44.-.- gi,- Date of Bal.. . -/6- - '>...? 7 19.17.
(If body is to be temporarily held,fill in space later)
Tbn 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 Re • tered
Number, and on the basis thereV HEREBY GRANT A PERMIT
,/4C,,a -
to . i T-h<-:-.1g-ify i.
the .e.e,e..-' to hold temp •ly d •, he body.
(Uncle r or n h vtag charge of corpse) (Inter,remor or ot ta bow))
Dated / , d 19.,4(/
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a body to any part of the State (imbioct 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 pR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE 'MADE
Date o icy�,Yv ..� was C-5-7 1'lO/
(Interment or Cremation)
•
(Name of Cemeter , Crematorium, etc.)
141 e.
Section Lot No. Grave No.
� � r4 - -
(Signed) � 1 fig-''�', ,..
(Person in charge)
Address /� / C • Cl� L fr-
.���GGG % %:_
Person in charge must return this permit to
the Registrar of his District within SEVEN (7) DAY
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.