Poreau, Nina ti
Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
R 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._.
Village
Dist. No �''�� (County or City
(If city, give st ddress)
Name f dec sed -...I.P.4.....,....0.(N..�A V Veteran
r Ingle, married, widowed, ( veteran, live name of,War)/ (`
Sex.. ... lor.t1) r divorced (write the word) Date of Death... ... . . ...... . ....J..(...19�r:..�"
Age . ... ars Months Day B. ce - A c ;1B
Cause of eatb. (�
Certificate was signkd by Y 1.:... -}c,.... .
M.D.
Address f.."
Place of B 1 (or :em,g,al .:.n... -n-i
(If body Is to tempoal _ 9 f. space later) -13
Cemetery. •4 Date of Burial . .19 ..7
..
(If body is to a emporarily hel. 1 In space later)
The Certificate of Death . aining 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 ccepted the same for registration, have recorded it in my Local o with the abo e stated Registered
N ,on ba, �a .f I HER Y GRANT A PERMIT (J ,
(Name) s)
the...... .... . .... .. to hold temporarily d the body.
(to er aker or person having charge corpse) (Inter,remove,or . dlsoose of[ w))
Dated . .:t 19. ....(,/ (Signed) . . . -
(( Z Loc Registrar
This Pe t is sufficient for the Removal (and Interment or Cremation) of a to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
•
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of 7/ was 19 Z T
(Interment or Cremation)
(Name or Cemetery, Crematorium, etc.)
Section AL Lot Igo. Grave No.
V
(Sided) (2 ///t<1-1--ei,-2-4jt
(Person Agi charge)
Address 0 )6+,Y c O OL
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 OFrENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.