Hafner, Dorothy Form vs.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or aubregiatrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER4IFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.D _.....___
i > -� Village ..„A
Dist. No..) to
�.Cotmty... .,��.:.Y.x. '�r'�'—_ or City ,�
�,//�`, ----.` (If city, give street address)
Name of deceased •f ,--).('I' 'J rf 9).4, -'1- Veteran --''
./'i . Single, married, widowed, -----
(If v ran. give name of War)
Sex... Color.../.F or divorced (write the wor )... ?':L Date of Death .. ;...2.9.....19. ..7
Age Years Mptii;hs fl.... a Birthplace
Cause of Death -sL.4!:-r . - r `4' ' 7-,
Certificate was signed by uc,,.... .'. kL.4 - M.D.
Address . i
Place of Burial or_ emoval `�� 'J --v —,,z. � �/
(If body 1s to be tempo ly held,II in apace late /
Cemetery Y .../:`.,.�s.,-.... /.,..�1„ 4-:�k::. r'x.>✓-. Date of Burial '� o� 19.Sa
(If body is to be temporarily held,Ill 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 SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same for re istration, have recorded it in my Local Record with the above stated Registered
Numb", oar?the b`ais thto
'f I HEREBY GRANT A PERMIT - ..7 �//
me) ----- (Address
the AG.1- ..r...'Z'' ,:.,;,r I to hold temporarily and, .IP.Y,: L-r the body.
(Underta a or person baring charge of corpse) (Inter,,Ae ove,or othe dispose of(sta bow])
Dated - 3,..........1 19..(,.( (Signed) .2t..
Local Registrar
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 SEXIUN OR PERSON IN CHARGE OF
PRINT SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date was 19 1
(Interment or
Name f Cemetery, Crematorium, etc.)
Section Lot No.3)5' Grave No.
(Signed) ]s,�� %C / 7'LZ
(Person in charge) -
Address
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 OFFhNSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.