Francis, Bartha Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt This Permit ear 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 Regist No.�.../..
Village .. 0
Dist. Not) 6 c)1 County C "�-" or City / �-twA �' iil 7
(If e'*y, give street ddress)
Name of deceased 01-12--"4 ..--/ ' Veteran We)
Single, married, widowed, (If v eran. live name of Wu)
Sex ? Color Vi or divorced (wnte the word) ate of Death f� 3 19 ('
Age 7 7 Years Months Days Birthplace •••�•
Cause of Death ct-1- t2 7/..-f k c..C,k-a-61..G.4,.,....-*4r4-''"
Certificate was signed bX., dr. f>iaa�,.Qa,....,, , M.D.
Address `2•1
Place of Burial (or Removal) �-��•���•'•�l1...` . "i ! �1 ill /
19
(If body is to beDoraclly held,fill in space later) (�
Cemetery - —s!..S., LIB-{= !A. Date of Burial
(If body is to be temporarily held, fill in 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
Number and ont�e basis; th�eof��`'I�HEREBY GRANT A PERMIT l;�j r� , 'Y����j 0_ C/l1 ,_.,
)/�lt�!) F Name`) \� �w`�', j� (/(Address):'`-C� ,...,
7
the �,. . to hold temporarily and (`"„/L the body.
(tindq ker ouersoA haAng charse,of corpse) (Inter,remo ,or of se dia*�ps) �oi(state bow])
Dated ,�5 1 �� 19C,?. (Signed) ` � '� m ��"
al Register
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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was._:" l� ,/ 19
(Interment or Cremation)/
(Name of Cemetery, Crematorium, etc.)
t ✓✓
Section ( Lot Noi 7- Grave No.
.1
(Signed) L- ter
(Person in charge)
r
Address ‘Zr
Person in charge must return this Perm. f 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 or 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.