Kocinei, Veronici NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
g 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 DURABLE BLACK INK. ��
Registered No.
ZOd..4. Town, Village /�i,
Dist. No. J L�__C?/ County �� , or City �JQ C` �=��'
If city, give street address)
Name of deceased /9.,__,r �-)22, --l. ./ t Veteran
(If veteran,give name of War)
Single, married,widowed, ]
Sex . . .G.or divorced (write the word) --. . . Date o Death // 191 d-- '
Age 1 Years __- Months Days Birthplace_ 4..1.-2- _ _
Cause of Death
Certificate was signed bFif.....y7tz.e- 7 M.D.
g do r t jAddress �_ !�: !_-s )fre„,7tie,.
Place of Burial or Removal) _ - ___-L�rr, A- -_-
(If body is to be m orarily held, I in sp ce later) I ���_
Cemetery_--______��/ iL e.,w_ Date of Burial // 19 .
(If body is to b temporarily held, fill in space later)
The CERTIFICATE OF DEATH 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 tjon, have recorded it 'n my Local Record w't the above stated Registered Number, nd on th basi- thereof I HERE-
BY GR A PERMI .
(Na 4.46 (Address)
the - �'� to hold temporarily and the body
(Unlertaker or er on aving barge of corpse) (Inter, remove, or otherwise dis ose of (state how))
Dated✓ 19__7� (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo y any p t ubject to local
cemetery or other regulations),unless removal is by common carrier, in which case a sit Permit (VS o. 62) is required.
FORM VS.61.(REV.6/63)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
C&Date of was 't /4 /
9 7
(Interment or Oaematioa-}_
(Name of Cemetery,
/Jz" ( .44-4^
Section / Lot No. ...V Grave No.
(Signed)
IV'--(tfrt & -
(Person in Charge) -
Address 4.4_.
,L
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 i
charge," and FILE PERMIT WITHIN THREE (3) DAY
with the Registrar of District in which cemetery is locate .
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of perms
are liable to a penalty of NOT LESS THAN FIVE DOLLZ
LARS NOR MORE THAN FIFTY DOLLARS FOR THLP
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.