Rozell, Frank Form V&IlL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir 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. Town Registered No— ../.e."
z/...
--2/-2,,--, Village
Dist. No.S..‘./.1./...Coun .ty - 417. ..‘ 7. 2---erYi---" — or City 1,11,,,&z-h.‘„4, L71,-14
(If city, give street address)
Name of deceased .---J7-a-1/1X 4 .1)-4',...-i-el-e. , Veteran ---Z---ct •(if teran, give name of War)
11„, Single, married, widokea, —72,124_72.7.:zi z.
Sex77.1 Color or divorced (write the word) Date of 119,a (.11.-.-.. l_.E..19,6-..
Age Yen Monthse. — Dvs Birthplace. rra ,).1 7
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Cause o7lZath. L.ei--:e--2.---L.<- ..----'-a 7-7.--rkzi,
7' ..- / M.D.
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Certificate ws_s signed by ,-;7r— , - te .,..q,
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Address -... 0,-1 ' _....1*(-- )r.-
Place of Burial or Removal). V-(2-4:./
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(If body it to be orar114Ifeld, z space later It
Cemetery :'....c..e..-( ..:-. .-t. '''.-..c,‘4.. .4. . .C.:;(7--- "
eil# Date of Burial ..4'...‘..N.... ./ eF-- 19.4: (
(If body is to b temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been present?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
tNournt_tcl. oaneez_ba,"s* ther9p1) II1E17BY GRANT A PERMITt.-7, , a 2/y
_ .,,, )#,..--4. .... 2,..,
(Address)
the /./A4-L.--KZ.-.0 ..--' to hold temporarily and. 4--- the body.
(Udertir or person having charge of corpse) r,remov Lpherwise dispose of[state how])
1.....).Dated ..C17,- , 19 6 X (Signed)4)11,010
Local Registrar
This Psrt is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ("abject 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 SEXTUI4 OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
(:-
Date o -)-1. 1/4 _ z L �G� 19_,6 L—,' :-
(Interment o )
Name of Ceme tery, remntorium etc.
I
Section — Trot No. Grave No.
e_-- `(Signed) / r
./,�
(PrnoSu charge) O 1.
Address f l' /. L' vGf L'-i ,e^' '_ �`�IrC�
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 wards
"No person in charge," aad FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRCTORS and UNDERTAKERS
violating the law relatire 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, tp report violations thereof.