Tamer, Domenica Form ys.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
er 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.
Dist. Nosh (I/ Coun (i) -a^--9--,--- or City /
(I1 el give street address)
Name deceased / Veteran
a.. Single, married, widowed, r rs / (If veteran. give name of War)/
S Color or divorced (write the word) � '`g� Date of g- 19 6 3
Age l Year . ...Mon . »»...Days Bi lace A
Cause of Death s7... .•..
Certificate was signed M.D.
Address -� ;p
Place of Burial (o Removal
(If body is to be to p arily hel . 1 sp a la )
Cemetery. - Date of Burial 6 r 19 .:3
(If body is to be temporarily field,fill in, pace later)
The Certificate of Death con fining 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 th above state Regist red
Num and on the ha ' th f HE GRANT A PERMIT
to.... I ya---,
(lifia�[i /l (Address)
they 3-�..'.. to hold temporaril and the body.
(Un9ertaker or person having charge corpse) (later,removq.or otherwise ttnose o [etatet!owl)
Dated '. . . 19 . (Signed) - - --'4 c ....R. � -.�->..- 'Y'�.
egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any art of the Nate (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 SI;XIUN OR PERSON IN CHARGE OF
PHEW SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of waste ""'"'"`- 19 43
(Interment or Crema )
4'.. ' (Name f Cemetery, Crematorium, etc.)
Section 4 a. Lot No. ! Grave'N3o.. 7.--
(Signed) 1 ,1, [ 0,-„,,,,,,9 Ct. _'�f�'ge"
(Person in charge)
Address C9 U • ' v O O
*?e-e- a t.i.,.( `
Person in charge waist return this ermit 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.