Tenofsky, Morris Form vs.6L 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 CERTIF1AT OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town egistered No-....... . ... .............
illage-
Dist. No.SLQ..County-LA a.ivl-g-A-^-. oi City,
(If ety, give street a ea)
Name of ceased .PItte.g..i.'. (4 es F $ i Veteran
(If veteran,veteran, give name of Wu)
Single, married, widowed,
Sex Color or divorced (write the word) Date of Death 19
Age <--1 2
Cause of De
ii•
Certificate was si by .. - • •••• • • . ..-
Address
10 A
1l(31 f abcoedy of.to13 t i * cOorrar1 --h#. 4 ce er ••1
Cemetery.- .. . ... ... .. • .t. Date of Burial (.. .2-.41.Y. 19. ..y
(If body La to be temporarily h d,fill 1,‘ space later)
The Certificate of Death cont..ning 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 c ted the same f r registration, hay recorded it in my Local 4;.r. with the . . .ve ptated Registered
N on the has' I HERES GRANT A PERMIT 0----ii
I i'v r
IC) .4. ....
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the ...... to hold tempora 'jf' and. 410t• the d .
(the: ter or ptreon having charfe cyrime) r (Inter,remoreC,..,.e seose of[state how])
Dated L. 191444 (Signed)
Local Registrar
This Permit is suñlcient for the Removal (and Interment or Cremation) of 6 body to any past 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 ! -�-, - I was `�., 7 19 4
(Interment or Cremation
(Name of Ceketery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in charge)
Address / / ���C� GY•'` �" `) .
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," sand FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law rela:ive to the return of permits
are liable to a penaltfi 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.