Suprenant, Mary Forma vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
410 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 CERTIF1C E OF
IITZ)
DEATH, LEGIBLY WR IN DURABLE BLACK INK. Town Registered No._....... .. . .............
V111-4e
Dist. No53.V..Coun . elf./1.... .g or-C.i.tat-
(If city, give etc is)
Nam of d ased/ a,, „.... . ,.., „„,,s, /1 , Veteran r)
,5... .o
a teran e . gi am ve ne of
i le, married, widowed,
Sex . lot,A) or divorced (wnte the word) ate of
Age kt7 'Aprars.. 0 0 lonths f—...Da lace...
Cause of eath .....e.A..c.ta4.. .... . .. . ... • ,,_
Certificate was si
. .... i„e•-'"---- ,
Address ..c"-- v •I 0
iltt__Place of Bu ' 1 (or Rdiovall ;..,dP • ' ,0'...-)
(If body la to be orarl I A 13 in Ake 1 1/4er) ri. ,
Date of Burial C / 2.,- ? 19C.y
(If body Is to p drily held,fit space later)
The Certificate of Death con .ining 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 re ' tration, have recorded it in my Loca ecord with abo e stated Registered
N on the asis the I HEREBY GRANT A PER
_ son.. .......„
the to hold tempora nd dress) the dy.
(TJ$derlaker or person haying chars of corpse) ( ter,remove, !A:11.e 'nose of[state bow])
Dated 1ri 19 (Signed)
b.,-al Registrar -• • ••••
This Perulit is sufficient for the Re val (and Interment or C ation) of a to any part of the State (aubject to lo 1
cemetery or other regulations),unless re oval is by common currier,in which case a ransit Permit (VS No. 62) is required.
ENDORSEMENT OF SE.xiUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of 1:A'1C""4 a K} was )i.‘.1...."-e• 12 19lo�'(Interment or Cremat
. Cti rt15 vs C€ .4 rel
(Name of Cemetery, Crematorium, etc.)
Section K e uJ Lot No. T Grave No. a
(Signed) VVt ' pit I
raon in charge)
Address 3J GAO
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.