Goldstein, Fannie -7_1a vs.sl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 'Phis 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 DURABLE BLACK INK. Town i, Registered No.
t,�/- pillage
Dist. No.J.4 ..Coca ..L: � ✓llls�' rY
( .. (If city, give stree ddress)
Name of deceased... .... ...,
�/ `..D....0.�'. .. S T F...I Veteran
Single, married, widowed, ( ran, give name of Wu) .
Sex...17 Color. I or divorced (wnte the word).. -t' Date of J�eath).. .. / 19Lr. ,.
Age rrs Mo t is .Days ,. BirthAlace
Cause of Death ,_,..n.-4.. .. 4..Xa::• a / � ".•• ./Neg-A
•
Certificate was si�ed lby �,G�:. "`-` M.D.
Address l u•\.•P.--':- ._ . ..
Place of B 1 (o �j /
(If body B tempo,:ril7.e ,;}�ln s c er) 19G .
Cemetery.. . s Date of Burial �.••• -•
(If body is to be temporarily he'd .11 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 pted the for regis ation, have recorded it in my Loaa cord with ' above stated Registered
u , and on th a thereof I/HEREB GRANT A PERMIT ti
the . .. ..� to hold tempora and dare)
, the body.
( dertaker or person having charge corpse) (Inter,.remove o be soose of (state bo
.t(
Dated........'L.— '2„..' 19.... `i (Signed) real a .,t''".....r..c
This Permit is sufficient for the Removal (and Interment or Cremation) of a y 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 PER DN IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of t was Ai_ ). i 19 4 .
(Interment or Cremation)
(Rase of Cemetery, rematorl, etc.)
Section Lot No. Grave No.
(Signed) i•' (3.1L--"
(Person in charge)
Address ! ) l/`tJ0/4'141'
Person in charge must 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.