Sunirsky, Hyman Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
g_ 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 CERTIFI ATE OF
LEGIBLY WRITTEN IN D RABLE BLACK INK DEATH, l Registered No._...gy�..l...._..........
Village Q / ,s ti) .)ed
Dist. No �rC�i County O°�`'("''L� or City
/vLi-li
(If city, give street address)
Name of deceased ( k/ 'v /1- r1/ Veteran .___
Ingle, married, widowed, (if veteran, give name of War)C; )
Sex ..Color �7r' or divorced (wnte the word) Date of Death /�'
Age Years.... :.Month . .....Days Birthplace
Cause of D ath r t�'�`�"""`���p -
Certificate was signed by 7 - uK . G ,�y �� / M.D.
Address . 7 . .,y.:.�.'. �/�.� /
Place of Burial (or emoval).... ) ��
(If body is to be temporarilg d,fill In pace 1
Cemetery .•...t..lcUl.. .:.... ...... 'f'b( Date of Burial rP 19
(If body is to be temporaril held,1111 in pace later)
The Certificate of Death cont i'ning the above state particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same form ' tration, have recorded it in my Local ecord� with the above stated Registered
Number, add o the basis HE---, /��L--T A PERMIT �'`� )Q-kU
to "ti^ .s
�._ -� -e.?a- the body.
the �� to hold tempora ' and Y
(tlnd r o perso aving charge otorpae) �( nter,re re,or oth s ose of[state how])
Dated CJ f-, 19.�. (Signed)
al *girt:or
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the 'fate (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
at-4
Date of 644 was 6 `°-'( (4, 19 ( 3
(Interment or Cremation)
)..�,,„
(Name o Ce tery, Crematorium, etc.)
Section Lot No. Grave No.
t
(Signed) ��: �..,+
(person in charge)
1 Address r\ A -g. 96di-
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 OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.