Gornbein, Bernard Form O&sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 CERTIF A�� OF
DEATH, LEGIBLY WRITTEN DURABLE BLACK INK Town Registered No.r_ C. ....
'�J�� Village-,
Dist. NO,Xo ,....County.. . .... «. (If c`cy, glue t address)
N e of deceased` .: .TeN ce b `') c .0..` . -/.. ./C / . ... Veteran Ll..).t
I
r ; Single, married, widowed, . ( f eteran, give name of War)
S . ... •. ....ColoL� or divorced (write the word) . .Date o eath.... •.. . 2) 1963
Age '2,,. .Ye Mo s _.....Days Birth ace.. o '"}
Cause of Death 1 �J
Certificate wa • by.. ,... M.D.
Addre .. ..
Place of Burial (or Removal) — -a'.
/�
(If body Is Araril' h Id,till in op a r) t� /, 1_/
Cemetery. .t.A.r . .R. -.4..Q. Date of Burial G! �J'Q
(If body Is to b temporarily held,fill in space later)
Thi Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I ted the same or registr ion, have recorded it in my Local ecord with the above stated Registered
N , the . hereof I EREBY GRANT A PERMIT
•
to. , \----: .
(Name) 7ldiZeis)
the.. .. . . ., to hold tempora ' and .. 'the-body.
(Uncle er or person having charge of corpse) (Inter,remove,or rwi .....rose of(state how])
Dated ( 19�.. (Signed). it
...
This a 't is sufficient for the Removal (and Interment or Cremation) of a y to any part of the State (subject to local
cemetery or other regulations),unless removal Is by common carrier, in which case a remit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of- er)'' ' was G=‘" 19
(Interment or lion)
i
/11•a-‘ me ot.-
4 L N6me oemetery, Crematorium, etc.)
Section Lot No. /6 0-- Grave No. /
1
(Signed) r e�k �• _ -�ti"��G* "-
(Person in charge)
/ / j.
Address e.
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
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.