Weiner, Robert Form VS.!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 DU LE BLACK INK. Town gistered No._._.._...._.
�
Dist No./ '2h County„,...„,--
`�-�ems- r ... or City d' G� -�'
z Z.
(if c'.t3', gtre street address)
Name of deceasedjg
's - —�(,.- --'� Veteran .2
le, married, widowed, +Z✓,� (If teran. give name of War)Sex ' dolordivorced (wnte th ord).1 � Date of eath... .1 l 19�1s
Age 7 Years Months ;.,...Days Birthplace... .. : Gr
Cause of Death r1�.eK .4r4.; �-c-4
Certificate was signed by * ,.... . . M.D.
Address ,, ,,.,.�° L'
Place of Burial (or Removal).. . .. C
(If body is to be temporarily held,till in space laterz,6,1411 - F)—
Cemetery Date of Burial.. . 19
(If body is to be temporarily held, fill in apace 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 ac pted the same for registration, have recorded it in my Local Re rd with the above stated Registered
Number and o� basis the I�H EB4 A PERMIL
(N'ame)
the to
t
to hold temporarily and the body.
MO taker or rsoa ving eharge corpse) (Inter,remove,or otb �disnooiA of(state howl)
Dated..,;..`.-' --c" iir lg lC"' (Signed), ,--e--, --e---4 .v .-a— "' V-''' _-• - ...
al Registrar
Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert-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 INTERMITS OR CREMATIONS
ARE MADE
Date of was 19 11-
(Interment or Cremation)
-4e---e‘rt
(Name o Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
C-N(Signed) tt'w-4-1A-_
(Person in charge)
Address b'o )1 11
Person in charge Deist return this 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.