Neuwirth, Anna Form vs.l><. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ea 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 CERTWICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__._...r7..(o.._
Village
Dist No '5-6 Coun or City %s--..-- ^ . -7
j (If city,give street a(Ldrees)
Name of deceased ,1.21. Y . , - .a.L,C"L�L�( Veteran -J"c�G
�/ Single, married, widowed, (II ran, give name of War)
Sex / Color �•X or divorced(wnte the word a-i Date
4 o eh L-<.-L 2 I
/1 9.
Age _ Ye. Months wDays Birthplace . L ( ez... )y
,
Cause of Death. .. a4:f .f1 .4- F!r22.)
Certificate was signed by . M.D.
U£ LAddress :yr • .y..
Place of Burial or Removal) O W>')... -:- .. . _i�`'`'. / / • �
(If body is to be p raspy held,fill injp�e later) ✓ , z
Cemetery i....tt�s.�..,. �,.• �''� �i-- - Date of Burial ��"1.,��]"� � •T
19.6...3
(If body is to be temporarily held,fill in space later) (..!
ThS 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 e beasis. �f EREBY GRANT A PERMIT 4 vto // ,,fir))) vz4'� (Address)the 1... . u v 'to hold temporarily and — howhe body.
(Uncle r or Demo having chargge of corpse) 6Vnter, em re, r otherwis�►isoose of(s )) �
Dated . ..2 191a._ .. (Signed) -L�_ ��� `a(� .) 1�
• •. Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 'late (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 0..- - � 19 (t2
.......:::).--
(Interment or co
lf7/2 . -
(Name of Cemetery, Crematorium, etc.
Section Lot No"--_, II Grave No. 2--
(Sig ' 'L--4'''' C/X 1---(
ri ✓� �..
(Person in charge)
,-.E
Address 1•2_,61., c.",.. _....--o.t0--s'
e, (i, ,_.....,,7 r
Person in ge must re n this Pelmit 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.