Mingo, Anna -or=vs.61- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit tan 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 CERTIF ATE_OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No.__.._.ter
la
Dist No.S .Ct °r ein/ft 9 "itcE, givesttl ddrees)
Name of d eased....A..Ti.NA M...•7•••�./J•NG.V ' Veteran Q %
Sin le, married, widowed, If veteran, give name of War)
`�,�, ( I /
Sex.. ... olo r lvorced wnte the word .. Date of Death... 19.442A
Age 7eath uuonths. Days / Bi ac
Cause . �'
Certificate was s• ed b ,� • M.D.
Address ... . ., ..• .•.. * , •
op . ' . 0 •. ..„ /
Place of Bgte...(or Re r) — l
(If body Is toor • 1,e u i• space later)
Cemetery.. ... Date of Burial - /f.. 19
(If body Is to be tempora y hel• y 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 have accepted the s• ,.e for registration, have recorded it in my Local Record with the above stated Registered
N and o. . • bat .f I HEREBY GRANT A PERMIT
' ` I )
to .. . . w ;.
• ��: ` ) dress
the to hold temporarilyrind the body.
(UnIlta r or pe n haring charge of corpse) (Inter,remove,y�b�he lsnose of[state bow]) t
Dated i.. 19.„.!_ (Signed) /fl
I.c�... ..
ocd'Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to any part of the State (eubjeet to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
i
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CATIONS
ARE MADE
Date of was L"v• 04 19 6 2-
(In tersent or Cremation)
�D f
t�IL(' (Name f Cemetery, Crematorlus, etc.)
Section5�J�G�/OL ALot No. / % Grave No._
(Sided)
.
0,,,,,P 221,,,__
( reon in charge
Address AI.'
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.