Lemelisky, Simon f L)"1`---4--ar--*-4--*A41 ,e -'1/ '
Form VS.O. NEW YORK STATE DEPARTMENT
?r,,.EALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 Registered No.____..i...... ..1_........
Village d,(2)--t-L,4 ?"--. i IDist No. - C,ounty-111(- - or City
(It zonT, give street address)
Name of deceased....44e. ..:k3111A-0-1-4:4-1 -4-,A.
. , Veteran
Single, married, widowed,
Of vigteran. give name of War)
the
t ,k_et_m_4„e_4 0../, 0_0_, 1 j
Sex . Color or divorced (write word) h Date oT Death. Nt 19 6
Age Ye rs Months Days Birthplace /67./...0/.4.c-P 7
Cause of Death. At-o_ft-, /-1
.
Certificate was signed ';''L.- a----,--6.f>,-,. trAr+..-66-- , M.D.
Address 92 41
Place of Burial (or Removal)......t6r.-nx:r.vk 4 4:' -1--4-Q-4-e-4--ef-c-'-e:::!-:\ t -"6 --X
(If body ts to be temporarily held,n1111 in spa ter i) 0, _ f."\
te..) ,--a—,, '' --.. 19 6 . -----
Cernetery....4-4'At,:71.-:-4.,-P,..-4A 0....5L-1.4,..,,.. Date of Burial
(If body le to be temporarily held,fill la apace is 4411(dx
Tho 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 Registered
NumbeyrAnd on the basis thereof I HEREBY GRANT A PERMIT
to (Ve17'--d-./.1-a0-.--.1 ,0 .-(4A-CL*4:14=e.... ,
.r -.- . A - -1(D-e-4,, qi7
c, ___,,„ame) 7-- (Address)
the , ...,L.k.-4— , :—....--,,... to hold temporari and . 1--r-,-- the body.
(14dertaker or person having charge of corpse) (Inter,remoye,or other2Z disnose of, state how])
Dated....4 ..e-r1-- 19....<- "2---- (Signed) SJ .. \-1...4----"C
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State bject 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 of was 1- S 19 CI
(Interment or Cremation)
(Name r' Cemetery,EZ}(11,,_
etc.)
Section Lot No. Grave No.
(Signed) - (it
Parao4. Ch.rBe)
Address 11 a L.1 Q, ,. bin@ws. 160--
Person in charge mist 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 OFF1NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.