Goldstein, Infant boy Form VS 61. 1-23-3S-25,000(17-5134)
NEW YORK STATE DE; ARTMENT OF HEALTH
OFFICIAL BURIAL (t REMOVAL)REMOVAL) PERMIT
OW' This Permit can be signed only by the Local Registrar City or Subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING alf acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY/ WRITTEN IN DURABLE BLACK INK.
Dist.No....Y tz d / l 7
Registered No. ./ .7
l own ' o �? .
County__ . Village._._.-'Y�^ �v ?� �
o� or City (If city,give street address)
Name of deceased. .._... /••••. ..._............ ,.._
, Single,tarried,widowed, _
Sex. ...........Color....__. ._...........or divorced (write the word) . .._..Date of Death r?....�,1...,`.t 19....3.s---
Age.__....._. ,_.....Year _..Mon _.... .. ._ .. Days Birthplace............ _..
Cause of Dea _ _ ____ _ _.. ... .__._ ._.__
... .... ... ...... ...........
Certificate was signed by,_
Address ..����� ._._........._...._.. _..._... _.. -�b€:�-�-:--1
ri
Place of Burial (or Removal).... .,.. .... ..._._
(If body is to be temporarily held,fill in space later)
Cemetery _. . ... .. _ Date of Buri .. . .. _1._ ...._. _19-)-->
(If body is to be temporarily held,fill in space la
The Certificate of Death containing the above stated particulars, having been presented me, after careful examina-
tion, 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 Local Record with the above stated Registered Number,
and on basis thereof I HEREBY GRANT A PE T �,
(Name) (Address)
to hold temporarily and_. _............. ......._. _...._....._....._......_... _......_._the body.
(
dertak rsonh es liming charge of corps t emove,or otherwise dispose of[state how]).
Dated.. ....., . ._....._....19 .. (Signed). _ . 4- - „_
Local Registrar •
• Pe t 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. 62) is required.
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