Spiegal, Katy NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
110- 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 • k D COMPL.ET ER-
TIFICATE OF DEATH, LEG�R.ITTEN IN DURABLE BLACK INK. 55
Regis -I No.
Town,�'
Dist. Na. 7Co my .,•
'e a (If city, gives et address)
Name o decease ..
Al—
C P..�EC A Veteran�ln`"�
(If veteran, give name of War)
Si gle, married, widowed, �, `C�
Sex or divorced (write the word Date of Death.( ..e...4.•i 196.7
Age 2i�, rs i .nths D s :- „:. . - if -AO 0,
Cause of-Death... .. • -- -.1 .• ts --..4••-r .e--•• ,- ss, ' % si r•v--••ot,Ati /
Certificate was ig d by....•i1,.f... . 7 ,._ - .. .. M.D.
Address. Q.. 4
•
Place of : .61 p(or Rem.v.� .. '
�(If bodyis t. em oraril het fl �a later) 1
Cemetery �1 , -._._ Date of Burial.._.1..1. , 196?
(If body is to be temporarily he• fill in s 4 e 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 h ted the sa e r registrat' n, have recorded it in my Local Re rd with t t a ve stated gistered
Nu b d on the b 's ereof I 'H EBY GRANT A P
e
(Name) (A dress
the.... ... .., .. to hold tempor.,ff' and he body
(rert er or person having charge of co se) '�� (Inter,remove other s pose of [state hoDated 1 19 ... (Signed)_
. Local Registrar
This Permi is sufficient for the Remov 1 (and Interment or Cremation) of a .dy 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 19
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section_—___ Lot No. Grave No.
(Signed) (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 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.