Cohen, Esther Form VS. 61. 8.16.3 5.50,000 (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
oar 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. _
Dist. NoJT o / Re 'stered No....{Y /
Town 9S 601— . .� 1 -. i/ ?jf
County .. ....�llh.�rs�m Village... - ,1 ,;(`
ate or City (If city, give street address)
Name of deceased.... f4�r'
Single, married, widowed, //i,�ce�
Sex. Color� or divorced (write the word)L! .... . Date of eath* j 19,.
Age ‘ Y� .rs .4" Months.. DaysBirthplace
Cause of Death..
Certificate was signed by .. . . . + M.D.
Address -' l.JKr j ll..�� 99,,��
Place of Bur 1 (or.Removal ....� ./...r!' 'e
(If body is to be,enyoranly held; fill space /
Cemetery . . '........a, ... Date of Burial ���*� •
✓....9, 19...?
(If body is tofb temporarily held, fill in space later)
The Certi ate of Death containing the above stated particulars, 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 the s1s thereof I HER Y GRANT A PERMIT f�
to �!
ame) Address)
the +— to hold temporarily an ... _ . the body.
(U er or p n ha yips.charge of sst�rp ) t Int emove, o ise dispose of [state how])
Dated i7/ 19.4)(9 (Signed) .... . . .
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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