Kaplan, Ida NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
s'This Permit can be signed only by the Local Registrar (Deputy or Subregierrar) 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...rJ._�....�, Regis' tered No. Q 3
Town �,,�,�� / �
County___ _.�(I�LI.La(lr-n-- _ _.__.Village ii a.'`_'".`._`. t?set_! frez /.
or City (If city. give street address)
Name of deceased..- - . ert—
/,,� �L Single, married, widowed, r
Sex _- .. _._._._.Color[l(�iL'.vt-or divorced (write t wword)f�"QP.`' ._.__.__Date Deatt _.'�12._: 2 19.7
Age.._. _.__Y - _._.TO._. hs.._._. (1 Day Ilirthptace. '.___.... ..... i%Y�=^d� AFC __�e �[w.�
Cause of Death.._. _ . .. -� ^rc3c�'��"� .--.--------_ — /.72.
Certificate was signed by_ ---.._lel ' _ _ M.D.
Address__—_-.—___==' 6 `.-'._. .,r._. -
Place of Burial or. Removal) ' ' _.........._._
re
(If bolt+r to be ri _� -
ly held, eu :n .pk /
Cemetery_. w..._�._._._....Date of Burial .__... ._Q) .w f...._..._......._19
(If body is to be a porarily held. Ill in space later)
*The artifice 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 a basis thereof I REBY GRANT A PERMIT
to ._ ._ ._. _._. _._- . __.._.....__._._ ._._._._ .. __._._._..
the._.._._._...._......._....__.._......__.__.. _..._..__.__ _...._...._._.__...__._.to hold temporal; y.
_the bod
(Unddaayaker or pulse to barge of ) nt move. or oth spose of Istate howl)
Dated..._.'.C. ....._.. .._...._. ._ �,c...._.19_)�._J (Signed)._._. _ _ __........._.__._..._..._._—._.
Local Regisau
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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