Lenortz, Rose NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
il:' 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURA LE BLACK INK. / ;
Re is red No.
l/ Town, Village
Dist. No. `" ec/ unty or City •
If city, give street address)
Name of deceased 'V-- a---x-,>:,2- .",--A__...-4 Veteran
(If veteran, give name of War)
k-.7 -Ll.2L1
Single, married,widowed, /
• or divorced (write the word) u�� —" Date of Death ..._...__ ._1 19.ZS-
Age C ? Years - Months _--,_-_ Days Birthplaceoly •
Cause of Death
Certificate was signed by __ __ --- _ .- M.D.
Address 5)c)
Place of Burial or Removal) _ 71--+51-.
(If body is to be orarily`;!el fit i p ce later) A-14-41 /
1-144-1%
Cemetery • l�- - Date of Burial /yo 19__-7
(If body is to be temporarily held ill in space later) /
The CERTIFICATE OF DEA H containing the above stated particulars, having been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registr ion, have rec rded it in my Local R ord with the above stated Registered Number, n on the ba ' thereof ERE-
BY GRA A P RMIT .
to 89
(Na e) (Ad ress)
the Ld( to hold temporarily and the body
(Unlertaker or person ha mg charge of corpse) Inte re v , or 7.,,,...ser„,spo f (state how)Dated 6/ 19..- (Signed) � � .e- = J
Local Registrar
This Permit is su ficient for the Removal (and Interment or Cremation) of a body to any part of the tate (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 V5.61.(REV.6/63)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of -``�` T was '/ / 19 V'5
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
(( � z
Section `1i"; ` C °' Lot No. Grave No.
(Signed) (?7_14'��'c'��'"y_
(Person in Charge)
Address .>�� /6 C� ,�
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 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 District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty Of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.