Seipel, Jennifer Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ilr 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.__/
// c— �/ Village ?t�,. -
Dist. No..�.Se.�l..Co ty....,��f-�:.r"'�- or City ....s �Z''.
„, (If city, give street address)
.�Z�yKr.•'.r.v C _�rh��
I�Tame of deceased... Veteran
Single, married, widowed, (If veteran, give name of Wu)
Sex.. Color or or divorced (wnte the word) Date of Death / — 19 ' —
A
Age Years. . Months Days Birthplace r., 6. • ••/("•••3
Cause or Death — „ g
e.A;; o
Certificate was signed by ... ... .�./- .. . M.D.
Address A
Place of Burial—(-or Removal) 0 Y�
(If body is to by rarily held,411 in space later) -
Cemetery... ,..1rk `t- = 3 Zza Date of Burial . ::u— 19
(If body la to be temporarily held,fill 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 same for registration, have recorded it in my Local Record with the above stated Registered
Number.* on the basis h �:/ .�REBY GRANT A PERMIT
� (Address)
the.,; � �''— to hold temporarily and, = '"" -1.<Y- the body.
(I... ker or person h g charge of corpse) (Inter, remove or otherwise)disoose of(state how))
! t ) t.�
Dated 19.6. .. (Signed) �• 1,e41 Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past 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 INTERMENTS OR CREMATIONS
ARE MADE
Date �- Ct� was
o Xli', /j5 19
(Interment—or ereemeteon)
1.
'-:////— -
/ crt-V �L/� L-jt
(Name of Cemetery, Crematorium, etc.)
Section Lot No. At 5-1(- Grave No. 7
(Signed) 7/
2/t4e/ L----a: ''-' f v'1 Z {_
/ (Person in charge)
� •
-
Address 0/ !l /
�, ,,.. ,k ----6 - --
A"-(<=;
Person_
Fin 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.