Kats, John 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 eath occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER-
TIFICATE OF DEATH, LEGIBLY R3TTEN IN DURABLE BLACK INK. I,l
Town, Vil1ege Registered No. 'jam
Dist. Na. .6.. . County i,. or—City+ .-CC/:�-
��-� (If city, give street address)
Name of deceased 1 d / 4 Veteran
(If ve r(!an, give name of War)
• e, married, widowed,
Sex , �.Q Q or.di-vorsed (write the word).-- � Date of Death 1_1!?/.�7 19
Age $ Years. Months ,Days Birthplace
Cause of-Death / c4X••..... ,.
Certificate was signed by �. M.D.
Address `i 1.,., y... �7..�j.• .,
-3
Place of Burial (or Remo -.r• .. ._. .c 4..,, . .
(If body is to be tempor ' , fill i space lat
Cemetery ��� ... .ate of Burial ...- 7 __ ?7 19
(If body is to be'Femporarily held, Il 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 f r registration, have recorded it in my Local Record with the above stated Registered
Numbeft nd o the, basis er 4 I HEREBY GRANT A PERMIT
to t..) . -yr,,,;,-.-.---, ‘ 7 4Pdrke a ifaitarm
a�n (Address)
)
the . .... a, to hold tern o - ' .nd cry-.. the body
(Undertaker or person having charge of corpse) n r move . e of ['state howl)
1 Dated ' 5 19-. (Sig ed _ r - ,if " '
Local Registrar j/
11
This Permit sufficient for the Removal (and Interment or Cremation) of a body to any part of the Sta (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, (2) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS 9R
CREMATIONS ARE MADE
Date of‘' ..7-'4 S-sr-y fwas
J 3 19
(Interment or Cremation)
(Name of Cemetery, C , e c.
Section` �L -L � I4ot Ne .' /2/Grave No._—
(Signed)
-
(Person in Charge)
Address �`-'� j /t '±
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.