Esposito, Rose 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 death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. �Q
/ Town, Village
Registered No.
J
�
Dist. No. ��0 ounty vv or City __ ._
If city, give street address)
Name of deceased___ -_. .. - Veteran
(If veteran, give ame of War)
Single, marri d,widowed, Q.�'
Sex . or divorced (write the word) ""'G ¢--Q-Date of Death g-" 197E-
Age Years Mont Days Birthplace
Cause of Death (� rYl c� •
Certificate was signed by _ ,/ � :.....- :.�a_- M.D.
Address orL. f
Place of Buria or Removal �._se� -7-c�_-__ _
(If body is to be porarily h d fill ins ace later)
Cemetery__ . �1L C%t t)' Date of Burial c /� 19-7�
(If body is to temporari y held, fill in space later)
The CERTIF CATE 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 registration, have recorded it in my LLocal Record with the above stated Registered Number, and o the basis th reo I HERE-
to GRANS I1� 1 '�1 'e �r C 7 jO CI
�` (Nam, ) (Address)
the "��'( to hold temporarily and the body
(Unlertaker or er on having charge of corpse) (Inter, re or o erwise pose of (state how))
Dated tZ//-.7 19-7r , (Signed)
This Permit is/sufficient for the Removal (and Interment or Cremation) of a b to any part oft�� 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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of 11 was 4.4)/ / 19 7e
(Interment or (aenvtinn)
1(721--yr..4
(Name of Cemetery, Creevealatium, etc.)
/ ems
Section Cg9 Lot No. Grave No.
(Signed)
(Person in Charge)
Y/
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
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 locate4
SEXTONS, FUNERAL DIRECTORS and UND
TAKERS violating the law relative to the return of perm s.�'
are liable to a penalty of NOT LESS THAN FIVE D -
LARS NOR MORE THAN FIFTY DOLLARS FOR THE;;~
FIRST OFFENSE. The law will be enforced. Local Regis-I
trars are required, under penalty, to report violations thereof.