Lenaux, Danathy Form vs.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 Registered No._..,[., .....7
e
Dist No i'O Coun ..lei-4- ,-Q-t^-_ or City
(If city, give street address)
Name of d eased �x—t ,,... l.. Veteran
p Single, marn , widowed, (If veteran, Given a of War)
Sex iT Color C ' or divorced (write the word)`- , Date of D �1�'4- '/:3...19.Cf:...=
Age ..�� ,....Years Months Days . Birthplace ...J" '
Cause of Death -r. : :za.., .... ...
Certificate was si ne9Ul . M.D.
Address ?.,,..:7 . i2 .:-� ~
Place of Burial (or Removal) T.-:,z. : -c .�.v,e-
(If body is to be tomooparily hell pace ter)
Cemetery .. ,- t- ,:a.
. Date of Burial ` �r�- l 19 (�
(If body is to be temporarily held,fill 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
Num , and on the bask,, thereof, I HER BY NT A PERMIT
to 44-Nas---- -rei Vcc___442........„,
i gyp- (Address)
th ....���. ' to hold temporaril and.. i. the body.
(Undertaker ppr person having charge of corpse) (Inter,rem e,or oth se disoosp of(state how))
Dated......._..- / 19..�:..f� (Signed) J. '1`k'�i.rr .. 'L..
al
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part 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 SrXiUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of_&2,�r��, -was ✓✓, / 19 6-3
(Interment or Cremation)
II
(Xe a of emetery, Crematorium, etc.)
Q
Section Lot No. Grav Q.
/14-4-"Sle-EQ6A,
(Signed)
(Person /Aarge)
V13
Address v
0-0
Person in ch ge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fram 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.