Schwartz, Isreal NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mar 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No./SY. Registered No
Town
County Village L...,le--e72---- ---1---'' --,',t.,1--,---
(If city, give street address)
Name of deceasede....4z4..ez_zz ?,/,‘ “___
Single,married,widowed, •
Sex,06. Color. or divorced (write the word) Date of e th ....� 19.)
Age Years r Months Days irthplace...;
Cause of Death _... .... 7
- Certificate was signed by _.. v.�,.. — M. D.
Address ... ........ L. /`d
Place of Burial (or, emoval) .r,--e= 4 :. ..., .. .. •
(If body is to be tempor r.y held, fill in spa later i- 11 _i
Cemetery ... h Date of Burial '7y� l9j'-
(If body is to be tempotarily held, fill in space later)
The Certificate of Death containing the above stated rticulars, having been presented to 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 t ,reof R Y GRANT A PERMIT � .,-�f�� ���
to , ��-�..
(Name) (Address)
the -fir - to hold temporaril _. the body.
(Under a e or ersonliving charge oi-For e, remove, of e se ' os [state )) l
Dated ..: n-- u (Signed)-f �'Local Registrar
This Permit 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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