Accocelli, Viola Form VS.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ltr This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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 RNo r
gi
Village
Dist. Na County.. ..FirG�.i.Cfar. or City ill —h Registere
__
.�
(If city,give street address)
Name of deceased V..aK ./ G ...ri.-e..e. _�.t._% Veteran
Single, married, widowed, v ((f iersn, live acme of wu)
Sek.„ -vie ,Color.;��1 .or divorced (wnte the word) &„Ga�i`z�4,Ps,✓Date of Death... ..-Lt.P-1,-,e... .. ....19... .1
Age.....-�/ Year Months�/ Days Birthplace... ,.. �..,
Cause of Death.... . .. . I,�,.�v-- : �
Certificate was signed by.. ., „ M.D.h� A��,••.
Address -�� . ... r�..� ..., .��r.�a.. �.- dam... .
Place of Burial (or Removal)....../...2 �-a..--../ '. -
(If body Is to be tempo�rilp held,fill is���a/'e dater) .x
Cemetery...:: `. .;- .t:,,... '!.( . -,...;...c.) - - - Date of urial ,/ 19..4/
(If body is to be temporarily held,fill in space later)
Tha Certificate of Death containing the above stated particulars, having been presented to e, 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
Nu and on a fete thereof I HE Y GRANT A PERMIT .
Lz
a dress)
th .. . .� to hold tempo ly and �t1 . e body.
( n estaYer or person at! charge of corpse) /' (Inter, or the Lose of[state how])
Dated.... .. utt4.r 7 19......... (Signed).(.�
. Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eubject to local
cemetery or other regulations), unless removal is by common carrier, in wh. case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INZERMFNTS OR CREMATIONS
ARE MADE
Date o was C(C; / 19 /
( terment or Creation)
1- (Nacre of Cedetery, Cremator!ai, eto.)
Section Lot No. Grave No. / b
r
(Signed) e)2. �.
(Person in charge)
Address / 2/ L
Person in charge Waist return his Permit to ..
the Registrar of his District within SEVEN (7) DAYS
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.