Goldman, Jennie Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt 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.
Dist. No...:,. S., Corm ......kfr....-.47.:e.1.--,..- or Village
(If city, give street address)
Name of deceased ( ... Jli<�:tnr .¢ �F 1;F��'YzCZ� Veteran -7Z_
Single, married, widowed, ���/ (If veIer. . ive name of War)
Sex..../ Color [ or divorced (wnte the word)..../,( ... . . ...Date of D . ., / 19
Age '7 7 Year ., Months Days . Birthplace ,./.. .
Cause of Death ... .:.Y.-.TA7 - --7-+-
Certificate was signed by •
. ..... M.D.
Address - y.4-4 -'7/ IX L../
Place of Burial (os Removal) , i .....1 .Lo
(If body Is to be tem arily held,fill in later)
Cemetery :7..f: .- / -t�''CV:7'1. Date of Burial j.,A.:4-1:44.- a' 19 6�(If body is to be temporarily held, fill I pace later)
The;Certificate of Death containing the above stated particulars, having been presented toafter careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ac pted the same for registration, have recor ed it in my Local Record with the above stated Registered
Number, the basis there kHEREBY GRA�A PERMIT
to r v ,,,t�2 Q .�.. J 6, +7
a ) (Address)
the , to hold temporarily and the body.
(tilde r or person having charge corpse) (I r, renfiir,or otherwise dispose of [state bow])
Dated .af 41- 12- 19. j (Signed) X G'J. `
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert 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
4
1
Date of was \\ 19 L1
(Interment or Cremati
ft-
(Name of Cemetery, torium, etc.)
Section Lot No. Grave No.
(Signed) �� L w"-
--
(Person in charge)
Address '� ~) J41V/V ' AaLt.t_._ {�
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
itittiAL lller�or "NTATE=
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.