Koch, Rachel NEW YORK STATE DEPARTMEN I OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deput. r 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
TIFICATE Q ;E 7, LEGI WRITTEN IN DURABLE BLACK INK. Register d No .
or A
Dist. No. .::•" ' Cot �"' ram...-. o r Cit
(If city, give tr t address)
Name of deceased Veteran
(If veteran, give name of War)
Single, married, widowed, /'
Sex..f ? or divorced (write the word).lN... ate of D s.7' pZegs 9�'� ,
Age 7 ...Years. Months ay Birthplace
• .
Cause of-Death 2 ft :.
Certificate was signed by t....
M.D.
Address �-•tC---69----
--7—..---21.Pl of Burial (or R oval).... ...... .......
(If body is to be temporari y , fill in space later) �,
47
Cemetery 1�--Q--x...•sZ--�..,. ,a....„6VV D e of Burial d 19.
(If body is to be temporarily held, fill 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 SATISFACTORY AS REQUIRED BY LAW
I have accepted the same for re istration, have recorded it in my Local Recor with the abov stated ,egistered
N pe -and on the basi here I HEREBY GRANT A PERMIT f
— Jam/
dress
the to hold temporarily and j the body
(Un
Cll7 ( g ) . . i r, vp„oy�otherwise dispose of [state how])
p
Dated 19.dor or pe on au .ng charge of Corp ) (Inter,Si ned
Lore:::
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, 82) 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 o `91- w 1�, L 3 el 19 7
(Interment or 1 .,)
(Name of Cemetery, Crematorium, etc.)
Section___.__ t 7 Lot Non- .5 /9 Grave No.__._V_
•
(Signed)
(Person in Charge)
Address
Person in charge must return this Permit to the Reg " trar
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.