Sagan, Sam NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. G
// �' Town, Village .--)Registered No �7
Dist. No. CPCi i County. .61/4-4 i' ''� or City j,,4:' .1G6�t 4.tLS-
(Ifcity, giveaddress)
Name of deceased 224-42.-lait---i
Veteran ✓�-.2Q--
veteran, give name of War)
.--/77 /� ///�/ Single, married, widowed,
Sex-._.l...Z_ZG1�r: e,' ' or divorced (write the word)././ f Date o€ athe / / 191.4
Age___o I Ye s Mont _-Days Birthplace:. y.%1.
Cause of-Death -
Certificate was signed�b.-^TT 21.i. _ M.D.
Address As; J� .,,, ; . %1 t
Place of Burial (or Remova4,0
,;:" 4,`.74-) ..1 - -ezzi r�
(If body is to be tt orarily held, flla 1 r)
Cemetery ate of Burial. _1 19.4.d
(If body is t be temporarily held fill in ace later)
The Certificate of Death containing the above stat 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 registration, have recorded it in my Local Record with the above stated Registered
Numbe , and on the basis thereof I HEREBY GRANT A PERMIT ; �,
to-:7'71ez1.t . :`./� • 7.240k3147,- ,,.::S I.442 _�CetC t....
(Name) dress)
the �'.,(-424 La- ,- to hold temporarily and � � a the body
(Elpdertakar or person having charge of corpse) ( ter,re , or otherwise dispose.of [state how])
Dated... 4 /2.. 19.6..6 (Signed) .
ta „.
Local egistrar
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.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of `::, was �� j-1 19 L C.
(Interment or Cremation)
\� 1/�qr
\\\NkKo_ kn \ 1\,i A X:,A� ,L.
(Name of Ce etery, Cre atorium, etc.)
Section_ Lot No. Grave No.
(Signed) \ \ci::: ,\ c "N'
(Person in Charge) �5
\\•,--, ,Q \ ..sstc '''''\,\,,h
,, .
"\\k
Address � �.
,, 1
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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict 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 required, under penalty,
to report violations thereof.